hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|LA,"To the best of its knowledge and belief, the 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 indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Lake Charles Memorial Hospital,7/1/2024,2.0.0,Lake Charles Memorial Hospital|Lake Charles Memorial Hospital for Women,"1701 Oak Park Boulevard Lake Charles, LA 70601|1900 W. Gauthier Rd. Lake Charles. LA 70605",720551963,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|MEDICARE|negotiated_dollar,standard_charge|AETNA|MEDICARE|negotiated_percentage,standard_charge|AETNA|MEDICARE|negotiated_algorithm,estimated_amount|AETNA|MEDICARE,standard_charge|AETNA|MEDICARE|methodology,additional_payer_notes|AETNA|MEDICARE,standard_charge|AETNA_MEDICAID|MEDICAID|negotiated_dollar,standard_charge|AETNA_MEDICAID|MEDICAID|negotiated_percentage,standard_charge|AETNA_MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|AETNA_MEDICAID|MEDICAID,standard_charge|AETNA_MEDICAID|MEDICAID|methodology,additional_payer_notes|AETNA_MEDICAID|MEDICAID,standard_charge|AETNA_MEDICARE_HMO|MEDICARE|negotiated_dollar,standard_charge|AETNA_MEDICARE_HMO|MEDICARE|negotiated_percentage,standard_charge|AETNA_MEDICARE_HMO|MEDICARE|negotiated_algorithm,estimated_amount|AETNA_MEDICARE_HMO|MEDICARE,standard_charge|AETNA_MEDICARE_HMO|MEDICARE|methodology,additional_payer_notes|AETNA_MEDICARE_HMO|MEDICARE,standard_charge|BCBS_MEDICARE_ADVANTAGE|MEDICARE|negotiated_dollar,standard_charge|BCBS_MEDICARE_ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|BCBS_MEDICARE_ADVANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|BCBS_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|BCBS_MEDICARE_ADVANTAGE|MEDICARE|methodology,additional_payer_notes|BCBS_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|BLUE_CROSS_BLUE_SHIELD_LA|COMMERCIAL|negotiated_dollar,standard_charge|BLUE_CROSS_BLUE_SHIELD_LA|COMMERCIAL|negotiated_percentage,standard_charge|BLUE_CROSS_BLUE_SHIELD_LA|COMMERCIAL|negotiated_algorithm,estimated_amount|BLUE_CROSS_BLUE_SHIELD_LA|COMMERCIAL,standard_charge|BLUE_CROSS_BLUE_SHIELD_LA|COMMERCIAL|methodology,additional_payer_notes|BLUE_CROSS_BLUE_SHIELD_LA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|CIGNA_BEHAVIORAL_HEALTH|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA_BEHAVIORAL_HEALTH|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA_BEHAVIORAL_HEALTH|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA_BEHAVIORAL_HEALTH|COMMERCIAL,standard_charge|CIGNA_BEHAVIORAL_HEALTH|COMMERCIAL|methodology,additional_payer_notes|CIGNA_BEHAVIORAL_HEALTH|COMMERCIAL,standard_charge|COUSHATTA_TRIBE_DEPT_OF_HEALTH|MEDICARE|negotiated_dollar,standard_charge|COUSHATTA_TRIBE_DEPT_OF_HEALTH|MEDICARE|negotiated_percentage,standard_charge|COUSHATTA_TRIBE_DEPT_OF_HEALTH|MEDICARE|negotiated_algorithm,estimated_amount|COUSHATTA_TRIBE_DEPT_OF_HEALTH|MEDICARE,standard_charge|COUSHATTA_TRIBE_DEPT_OF_HEALTH|MEDICARE|methodology,additional_payer_notes|COUSHATTA_TRIBE_DEPT_OF_HEALTH|MEDICARE,standard_charge|FIRST_HEALTH|COMMERCIAL|negotiated_dollar,standard_charge|FIRST_HEALTH|COMMERCIAL|negotiated_percentage,standard_charge|FIRST_HEALTH|COMMERCIAL|negotiated_algorithm,estimated_amount|FIRST_HEALTH|COMMERCIAL,standard_charge|FIRST_HEALTH|COMMERCIAL|methodology,additional_payer_notes|FIRST_HEALTH|COMMERCIAL,standard_charge|HUMANA|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA|COMMERCIAL,standard_charge|HUMANA|COMMERCIAL|methodology,additional_payer_notes|HUMANA|COMMERCIAL,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE|MEDICARE,standard_charge|HUMANA_MEDICARE|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE|MEDICARE,standard_charge|LWCC|WORK COMP|negotiated_dollar,standard_charge|LWCC|WORK COMP|negotiated_percentage,standard_charge|LWCC|WORK COMP|negotiated_algorithm,estimated_amount|LWCC|WORK COMP,standard_charge|LWCC|WORK COMP|methodology,additional_payer_notes|LWCC|WORK COMP,standard_charge|MEDICAID|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|MEDICAID,standard_charge|MEDICAID|MEDICAID|methodology,additional_payer_notes|MEDICAID|MEDICAID,standard_charge|MEDICAID_ADVANTAGE|MEDICAID|negotiated_dollar,standard_charge|MEDICAID_ADVANTAGE|MEDICAID|negotiated_percentage,standard_charge|MEDICAID_ADVANTAGE|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MEDICAID_ADVANTAGE|MEDICAID|methodology,additional_payer_notes|MEDICAID_ADVANTAGE|MEDICAID,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|MEDICARE_ADVANTAGE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE_ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE_ADVANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE_ADVANTAGE|MEDICARE,standard_charge|MEDICARE_ADVANTAGE|MEDICARE|methodology,additional_payer_notes|MEDICARE_ADVANTAGE|MEDICARE,standard_charge|MERITAIN|COMMERCIAL|negotiated_dollar,standard_charge|MERITAIN|COMMERCIAL|negotiated_percentage,standard_charge|MERITAIN|COMMERCIAL|negotiated_algorithm,estimated_amount|MERITAIN|COMMERCIAL,standard_charge|MERITAIN|COMMERCIAL|methodology,additional_payer_notes|MERITAIN|COMMERCIAL,standard_charge|PHCS|COMMERCIAL|negotiated_dollar,standard_charge|PHCS|COMMERCIAL|negotiated_percentage,standard_charge|PHCS|COMMERCIAL|negotiated_algorithm,estimated_amount|PHCS|COMMERCIAL,standard_charge|PHCS|COMMERCIAL|methodology,additional_payer_notes|PHCS|COMMERCIAL,standard_charge|PPO_PLUS|COMMERCIAL|negotiated_dollar,standard_charge|PPO_PLUS|COMMERCIAL|negotiated_percentage,standard_charge|PPO_PLUS|COMMERCIAL|negotiated_algorithm,estimated_amount|PPO_PLUS|COMMERCIAL,standard_charge|PPO_PLUS|COMMERCIAL|methodology,additional_payer_notes|PPO_PLUS|COMMERCIAL,standard_charge|TRICARE|MEDICARE|negotiated_dollar,standard_charge|TRICARE|MEDICARE|negotiated_percentage,standard_charge|TRICARE|MEDICARE|negotiated_algorithm,estimated_amount|TRICARE|MEDICARE,standard_charge|TRICARE|MEDICARE|methodology,additional_payer_notes|TRICARE|MEDICARE,standard_charge|UNITED_HEALTHCARE|COMMERCIAL|negotiated_dollar,standard_charge|UNITED_HEALTHCARE|COMMERCIAL|negotiated_percentage,standard_charge|UNITED_HEALTHCARE|COMMERCIAL|negotiated_algorithm,estimated_amount|UNITED_HEALTHCARE|COMMERCIAL,standard_charge|UNITED_HEALTHCARE|COMMERCIAL|methodology,additional_payer_notes|UNITED_HEALTHCARE|COMMERCIAL,standard_charge|UNITED_HEALTHCARE_BEHAVORIAL_HEALTH|COMMERCIAL|negotiated_dollar,standard_charge|UNITED_HEALTHCARE_BEHAVORIAL_HEALTH|COMMERCIAL|negotiated_percentage,standard_charge|UNITED_HEALTHCARE_BEHAVORIAL_HEALTH|COMMERCIAL|negotiated_algorithm,estimated_amount|UNITED_HEALTHCARE_BEHAVORIAL_HEALTH|COMMERCIAL,standard_charge|UNITED_HEALTHCARE_BEHAVORIAL_HEALTH|COMMERCIAL|methodology,additional_payer_notes|UNITED_HEALTHCARE_BEHAVORIAL_HEALTH|COMMERCIAL,standard_charge|UNITED_HEALTHCARE_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|UNITED_HEALTHCARE_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|UNITED_HEALTHCARE_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|UNITED_HEALTHCARE_MEDICARE|MEDICARE,standard_charge|UNITED_HEALTHCARE_MEDICARE|MEDICARE|methodology,additional_payer_notes|UNITED_HEALTHCARE_MEDICARE|MEDICARE,standard_charge|VANTAGE_COMMERCIAL|MEDICARE|negotiated_dollar,standard_charge|VANTAGE_COMMERCIAL|MEDICARE|negotiated_percentage,standard_charge|VANTAGE_COMMERCIAL|MEDICARE|negotiated_algorithm,estimated_amount|VANTAGE_COMMERCIAL|MEDICARE,standard_charge|VANTAGE_COMMERCIAL|MEDICARE|methodology,additional_payer_notes|VANTAGE_COMMERCIAL|MEDICARE,standard_charge|VERITY|COMMERCIAL|negotiated_dollar,standard_charge|VERITY|COMMERCIAL|negotiated_percentage,standard_charge|VERITY|COMMERCIAL|negotiated_algorithm,estimated_amount|VERITY|COMMERCIAL,standard_charge|VERITY|COMMERCIAL|methodology,additional_payer_notes|VERITY|COMMERCIAL,standard_charge|VETERANS_CHOICE_TRIWEST|MEDICARE|negotiated_dollar,standard_charge|VETERANS_CHOICE_TRIWEST|MEDICARE|negotiated_percentage,standard_charge|VETERANS_CHOICE_TRIWEST|MEDICARE|negotiated_algorithm,estimated_amount|VETERANS_CHOICE_TRIWEST|MEDICARE,standard_charge|VETERANS_CHOICE_TRIWEST|MEDICARE|methodology,additional_payer_notes|VETERANS_CHOICE_TRIWEST|MEDICARE,standard_charge|WORKERS_COMPENSATION|COMMERCIAL|negotiated_dollar,standard_charge|WORKERS_COMPENSATION|COMMERCIAL|negotiated_percentage,standard_charge|WORKERS_COMPENSATION|COMMERCIAL|negotiated_algorithm,estimated_amount|WORKERS_COMPENSATION|COMMERCIAL,standard_charge|WORKERS_COMPENSATION|COMMERCIAL|methodology,additional_payer_notes|WORKERS_COMPENSATION|COMMERCIAL,standard_charge|AMERIHEALTH|CARITAS_MEDICAID|negotiated_dollar,standard_charge|AMERIHEALTH|CARITAS_MEDICAID|negotiated_percentage,standard_charge|AMERIHEALTH|CARITAS_MEDICAID|negotiated_algorithm,estimated_amount|AMERIHEALTH|CARITAS_MEDICAID,standard_charge|AMERIHEALTH|CARITAS_MEDICAID|methodology,additional_payer_notes|AMERIHEALTH|CARITAS_MEDICAID,standard_charge|AMERIHEALTH|MEDICAID|negotiated_dollar,standard_charge|AMERIHEALTH|MEDICAID|negotiated_percentage,standard_charge|AMERIHEALTH|MEDICAID|negotiated_algorithm,estimated_amount|AMERIHEALTH|MEDICAID,standard_charge|AMERIHEALTH|MEDICAID|methodology,additional_payer_notes|AMERIHEALTH|MEDICAID,standard_charge|UHC|MEDICAID|negotiated_dollar,standard_charge|UHC|MEDICAID|negotiated_percentage,standard_charge|UHC|MEDICAID|negotiated_algorithm,estimated_amount|UHC|MEDICAID,standard_charge|UHC|MEDICAID|methodology,additional_payer_notes|UHC|MEDICAID,standard_charge|LA_HEALTHCARE|CONNECT_MEDICAID|negotiated_dollar,standard_charge|LA_HEALTHCARE|CONNECT_MEDICAID|negotiated_percentage,standard_charge|LA_HEALTHCARE|CONNECT_MEDICAID|negotiated_algorithm,estimated_amount|LA_HEALTHCARE|CONNECT_MEDICAID,standard_charge|LA_HEALTHCARE|CONNECT_MEDICAID|methodology,additional_payer_notes|LA_HEALTHCARE|CONNECT_MEDICAID,standard_charge|MAGELLAN|MEDICAID|negotiated_dollar,standard_charge|MAGELLAN|MEDICAID|negotiated_percentage,standard_charge|MAGELLAN|MEDICAID|negotiated_algorithm,estimated_amount|MAGELLAN|MEDICAID,standard_charge|MAGELLAN|MEDICAID|methodology,additional_payer_notes|MAGELLAN|MEDICAID,standard_charge|TAKE_CHARGE|MEDICAID|negotiated_dollar,standard_charge|TAKE_CHARGE|MEDICAID|negotiated_percentage,standard_charge|TAKE_CHARGE|MEDICAID|negotiated_algorithm,estimated_amount|TAKE_CHARGE|MEDICAID,standard_charge|TAKE_CHARGE|MEDICAID|methodology,additional_payer_notes|TAKE_CHARGE|MEDICAID,standard_charge|CHAMPUS|VA|negotiated_dollar,standard_charge|CHAMPUS|VA|negotiated_percentage,standard_charge|CHAMPUS|VA|negotiated_algorithm,estimated_amount|CHAMPUS|VA,standard_charge|CHAMPUS|VA|methodology,additional_payer_notes|CHAMPUS|VA,standard_charge|CORRECT_CARE|MEDICARE|negotiated_dollar,standard_charge|CORRECT_CARE|MEDICARE|negotiated_percentage,standard_charge|CORRECT_CARE|MEDICARE|negotiated_algorithm,estimated_amount|CORRECT_CARE|MEDICARE,standard_charge|CORRECT_CARE|MEDICARE|methodology,additional_payer_notes|CORRECT_CARE|MEDICARE,standard_charge|CIGNA|MEDICARE_ACCESS|negotiated_dollar,standard_charge|CIGNA|MEDICARE_ACCESS|negotiated_percentage,standard_charge|CIGNA|MEDICARE_ACCESS|negotiated_algorithm,estimated_amount|CIGNA|MEDICARE_ACCESS,standard_charge|CIGNA|MEDICARE_ACCESS|methodology,additional_payer_notes|CIGNA|MEDICARE_ACCESS,standard_charge|VETERANS_ADMINISTRATION|MEDICARE|negotiated_dollar,standard_charge|VETERANS_ADMINISTRATION|MEDICARE|negotiated_percentage,standard_charge|VETERANS_ADMINISTRATION|MEDICARE|negotiated_algorithm,estimated_amount|VETERANS_ADMINISTRATION|MEDICARE,standard_charge|VETERANS_ADMINISTRATION|MEDICARE|methodology,additional_payer_notes|VETERANS_ADMINISTRATION|MEDICARE,standard_charge|STERLING|HMO_MEDICARE|negotiated_dollar,standard_charge|STERLING|HMO_MEDICARE|negotiated_percentage,standard_charge|STERLING|HMO_MEDICARE|negotiated_algorithm,estimated_amount|STERLING|HMO_MEDICARE,standard_charge|STERLING|HMO_MEDICARE|methodology,additional_payer_notes|STERLING|HMO_MEDICARE,standard_charge|MEDICARE|RAILROAD|negotiated_dollar,standard_charge|MEDICARE|RAILROAD|negotiated_percentage,standard_charge|MEDICARE|RAILROAD|negotiated_algorithm,estimated_amount|MEDICARE|RAILROAD,standard_charge|MEDICARE|RAILROAD|methodology,additional_payer_notes|MEDICARE|RAILROAD,standard_charge|VANTAGE|MEDICARE_HMO|negotiated_dollar,standard_charge|VANTAGE|MEDICARE_HMO|negotiated_percentage,standard_charge|VANTAGE|MEDICARE_HMO|negotiated_algorithm,estimated_amount|VANTAGE|MEDICARE_HMO,standard_charge|VANTAGE|MEDICARE_HMO|methodology,additional_payer_notes|VANTAGE|MEDICARE_HMO,standard_charge|WELLCARE|MEDICARE|negotiated_dollar,standard_charge|WELLCARE|MEDICARE|negotiated_percentage,standard_charge|WELLCARE|MEDICARE|negotiated_algorithm,estimated_amount|WELLCARE|MEDICARE,standard_charge|WELLCARE|MEDICARE|methodology,additional_payer_notes|WELLCARE|MEDICARE,standard_charge|min,standard_charge|max,additional_generic_notes
Automated urinalysis test,1002884,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,pays at 100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
COVID-19 BY PCR(ID NOW) - EM,1002885,CDM,300,RC,U0002,HCPCS,Outpatient,,,714,428.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,100,,,Fee Schedule,100% of UHC Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,642.6,
STREP GRP A SCREEN - EM,1002886,CDM,300,RC,87651,HCPCS,Outpatient,,,88,52.8,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
INFLUENZA  A  AND B SCREEN - EM,1002887,CDM,300,RC,87502,HCPCS,Outpatient,,,596,357.6,,339.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,95.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,417.2,70,,,percent of total billed charges,70% of total billed charges,447,75,,,percent of total billed charges,75% of total billed charges,172.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.3,350,,,Fee Schedule,350% of CMS OPPS Rate,97.71,102,,,Fee Schedule,102% of CMS OPPS Rate,455.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,268.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,100,,,Fee Schedule,100% of UHC Fee Schedule,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,220.34,230,,,Fee Schedule,230% of CMS OPPS Rate,286.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,536.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,536.4,
Blood test to assess for pregnancy,1002888,CDM,301,RC,84703,HCPCS,Outpatient,,,221.65,132.99,,26.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.16,70,,,percent of total billed charges,70% of total billed charges,166.24,75,,,percent of total billed charges,75% of total billed charges,13.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.32,350,,,Fee Schedule,350% of CMS OPPS Rate,7.67,102,,,Fee Schedule,102% of CMS OPPS Rate,169.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,99.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of UHC Fee Schedule,155.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,17.29,230,,,Fee Schedule,230% of CMS OPPS Rate,106.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,199.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,199.49,
"New patient office or other outpatient visit, typically 10 minutes",1002889,CDM,510,RC,99202,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"New patient office or other outpatient visit, typically 30 min",1002890,CDM,510,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
Outpatient visit of established patient not requiring a physician,1002891,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,1002892,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",1002893,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",1002894,CDM,510,RC,99214,HCPCS,Outpatient,,,168,100.8,,30.24,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,75,,,percent of total billed charges,75% of total billed charges,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,168,
"Established patient office or other outpatient, visit typically 40 minutes",1002895,CDM,510,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,40.26,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,111.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.26,223.68,
EKG PANEL,1002896,CDM,510,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,153.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,362.64,
PPD TB INTRADERMAL TEST,1002897,CDM,300,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
Immunization administration by a medical assistant or nurse,1002898,CDM,771,RC,90471,HCPCS,Outpatient,,,50.72,30.43,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.36,50,,,percent of total billed charges,pays at 50% of total billed charges,35.5,70,,,percent of total billed charges,70% of total billed charges,38.04,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,50.72,103,,,Fee Schedule,103% of CMS OPPS Rate,38.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,22.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,35.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,24.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86.64,100,,,Case rate,pays based on per visit rate,45.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,22.82,217.13,
N/A ADMIN VACCINE EA ADDL,1002899,CDM,771,RC,90472,HCPCS,Outpatient,,,40.58,24.35,,7.3,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,7.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.29,50,,,percent of total billed charges,pays at 50% of total billed charges,28.41,70,,,percent of total billed charges,70% of total billed charges,30.44,75,,,percent of total billed charges,75% of total billed charges,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,42,
INJECTION SQ OR IM,1002900,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
DIRECT ADMISSION FOR OBSERVATION,3000000,CDM,762,RC,G0379,HCPCS,Outpatient,,,689.6,413.76,,1763.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1061.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,482.72,70,,,percent of total billed charges,70% of total billed charges,517.2,75,,,percent of total billed charges,75% of total billed charges,896.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,551.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1744,350,,,Fee Schedule,350% of CMS OPPS Rate,508.25,103,,,Fee Schedule,103% of CMS OPPS Rate,527.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,310.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,482.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,413.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2247,100,,,Case rate,Pays based on per visit ,482.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,620.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,108.06,2247,
3T SURGICAL OBSERVATION HR,3010007,CDM,762,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,2247,
OBSV RM PER 1 HR 2N,3011010O,CDM,762,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,2247,
2T HEMATOLOGY ONCOLOGY OBSERVATION HR,3020006,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
OBSV RM PER 1 HR 2T,3021010,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
HYDRATION INFUSION INITIAL HR,3021015,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3021016,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3021017,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3021018,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3021019,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3021020,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3021021,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3021022,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3021023,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3021024,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
Immunization administration by a medical assistant or nurse,3021025,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
IRRIG DRUG DELIVERY DEVIC,3021026,CDM,510,RC,96523,HCPCS,Outpatient,,,123.75,74.25,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.81,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,94.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,59.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,19.39,184.98,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3026013,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
OBSERVATION ROOM PER 1 HR 3T,3030003O,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
3T SURGICAL ICU OBSERVATION HR,3030008,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
CARDIAC OUTPUT DAILY INTL,3030200,CDM,480,RC,93561,HCPCS,Outpatient,,,604.8,362.88,,108.86,18,,,percent of total billed charges,pays at 18% of total charges,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.36,70,,,percent of total billed charges,70% of total billed charges,453.6,75,,,percent of total billed charges,75% of total billed charges,302.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,483.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1196,100,,,Case rate,Pays based on per visit ,423.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,604.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.77,1196,
INTUBATION OBTURATOR,3034205,CDM,272,RC,,,Outpatient,,,131.5,78.9,,23.67,18,,,percent of total billed charges,pays at 18% of total charges,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.75,50,,,percent of total billed charges,pays at 50% of total billed charges,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,65.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,131.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.61,131.5,
TRANSV PACE ELECTRODES,3034228,CDM,272,RC,,,Outpatient,,,443,265.8,,79.74,18,,,percent of total billed charges,pays at 18% of total charges,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.5,50,,,percent of total billed charges,pays at 50% of total billed charges,310.1,70,,,percent of total billed charges,70% of total billed charges,332.25,75,,,percent of total billed charges,75% of total billed charges,221.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,354.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,265.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,338.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,310.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,443,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,398.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.42,443,
TELEMETRY MONITORING,3035000,CDM,900,RC,93228,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.94,278,
Immunization administration by a medical assistant or nurse,3036360,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
HYDRATION INFUSION INITIAL HR,3036363,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3036364,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3036365,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3036366,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3036367,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3036368,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3036369,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3036370,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3036372,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3036373,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
OBSV RM PER 1 HR  4T,3040008,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
ADMIT PRODUCTIVITY ONLY,3040011,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
POST PROCEDURE PRODUCTIVITY ONLY,3040012,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PHONE ADMIT PRODUCTIVITY ONLY,3040013,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PRE ADMIT PRODUCTIVITY ONLY,3040014,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
4T NURSING OBSERVATION HR,3040016,CDM,762,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,2247,
4T NURSING OBSERVATION HR,3040017,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
DEBRIDEMENT SUBCUT TISSUE 1ST 20SQ CM,3040018,CDM,761,RC,11042,HCPCS,Outpatient,,,1003.52,602.11,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1003.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,752.64,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,802.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,767.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,451.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,702.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,602.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,702.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,481.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,903.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,1200.6,
DEBRIDEMENT SUBCUT TISSUE ADD'L 20SQ CM,3040019,CDM,761,RC,11045,HCPCS,Outpatient,,,1003.52,602.11,,180.63,18,,,percent of total billed charges,pays at 18% of total charges,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.64,75,,,percent of total billed charges,75% of total billed charges,501.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,802.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,602.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,767.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,702.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,602.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1003.52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,903.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.25,1003.52,
CARDIOVERSION,3040030,CDM,480,RC,92960,HCPCS,Outpatient,,,1452,871.2,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges,1089,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1110.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,653.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,696.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,1892.75,
PSEUDOANEURYSM COMPRES W US,3040031,CDM,481,RC,76936,HCPCS,Outpatient,,,279.92,167.95,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.94,70,,,percent of total billed charges,70% of total billed charges,209.94,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,223.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,214.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,125.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,195.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,134.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,251.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.86,901.29,
SAFEGUARD DSG,3040032,CDM,272,RC,,,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,50,,,percent of total billed charges,pays at 50% of total billed charges,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,125,
INC & DRNG ABSCESS CMPLCTD OR MULTI,3040061,CDM,761,RC,10061,HCPCS,Outpatient,,,525,315,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,525,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,393.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,401.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,252,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,1200.6,
ARCHER ADOL OBS ROOM CRISIS UNIT,3041006,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
ARCHER ADOLOSCENT OBSERVATION HR,3041007,CDM,762,RC,G0378,HCPCS,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,2247,
6T MEDICAL SURGICAL OBSERVATION HR,3041011,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
Outpatient visit of established patient requiring a physician,3046212,CDM,510,RC,99212,HCPCS,Outpatient,,,152,91.2,,27.36,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,152,
INJECT PSEUDOANEURYSM,3046377,CDM,761,RC,36002,HCPCS,Outpatient,,,736,441.6,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,552,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,588.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,563.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,331.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,353.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,662.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,115.33,1861.73,
5T ORTHO NEURO TRAUMA OBSERVATION HR,3050007,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
OBSV RM PER 1 HR  5T,3051010,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
CLSD TX NASAL FX W MANPLTN,3051320,CDM,761,RC,21320,HCPCS,Outpatient,,,3043,1825.8,,9155.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3043,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2586.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2586.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4214.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,2282.25,75,,,percent of total billed charges,75% of total billed charges,4655.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2434.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9052.45,350,,,Fee Schedule,350% of CMS OPPS Rate,2638.14,103,,,Fee Schedule,103% of CMS OPPS Rate,2327.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2130.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1825.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2130.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5948.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1460.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2738.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3043,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.35,9155.9,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",3052011,CDM,761,RC,12011,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,581.14,
Immunization administration by a medical assistant or nurse,3055020,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
HYDRATION INFUSION INITIAL HR,3055022,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3055023,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3055024,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3055025,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3055026,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3055027,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3055028,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3055029,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3055030,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3055031,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
PICU PRODUCTIVITY ONLY,3060011,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
6T PEDI / PEDI ICU OBSERVATION HR,3060013,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
Draining or injecting medication into a major joint/bursa without ultrasound,3060610,CDM,761,RC,20610,HCPCS,Outpatient,,,317.9,190.74,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,238.43,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.81,875,
6T PEDIATRIC OBSERVATION HR,3061010,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
INJECTION SQ OR IM,3062353,CDM,949,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3062534,CDM,761,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3062535,CDM,761,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,148.5,
HYDRATION INFUSION INITIAL HR,3062536,CDM,761,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3062537,CDM,761,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,136.34,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3062538,CDM,761,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3062539,CDM,761,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,136.34,
THER/PROP/DIAG SEQ,3062540,CDM,761,RC,96567,HCPCS,Outpatient,,,446.85,268.11,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,335.14,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,357.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,341.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,201.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,214.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,402.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.02,581.14,
IRRIG DRUG DELIVERY DEVIC,3062541,CDM,510,RC,96523,HCPCS,Outpatient,,,106.7,64.02,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.03,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,81.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,48.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,51.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,96.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.72,184.98,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3062542,CDM,761,RC,96376,HCPCS,Outpatient,,,83.6,50.16,,15.05,18,,,percent of total billed charges,pays at 18% of total charges,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.7,75,,,percent of total billed charges,75% of total billed charges,41.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,75.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,83.6,
CONCURRENT NONCHEMO INFUSION ADDL HR,3062546,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
CHEMO IV INITIAL HR >15 MIN <= 1HR,3062547,CDM,335,RC,96413,HCPCS,Outpatient,,,600.77,360.46,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,420.54,70,,,percent of total billed charges,70% of total billed charges,450.58,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,480.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,459.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,270.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,420.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,420.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,288.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,540.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,94.14,1070.43,
Chemotherapy infusion-each additional hour,3062548,CDM,335,RC,96415,HCPCS,Outpatient,,,84,50.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,64.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,75.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,13.16,400,
Immunization administration by a medical assistant or nurse,3063013,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
CATHETERIZATION CLLCTN URINE SPECIMEN,3069612,CDM,761,RC,P9612,HCPCS,Outpatient,,,7.5,4.5,,30.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,5.63,75,,,percent of total billed charges,75% of total billed charges,15.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.99,350,,,Fee Schedule,350% of CMS OPPS Rate,8.74,102,,,Fee Schedule,102% of CMS OPPS Rate,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,7.5,230,,,Fee Schedule,230% of CMS OPPS Rate,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,1.18,30.33,
DEB SUBQ TISSUE 20 SQ CM/<,3070003,CDM,761,RC,11042,HCPCS,Outpatient,,,825,495,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,825,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,618.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,660,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,631.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,371.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,495,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,577.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,396,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,742.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,825,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,1200.6,
7T MEDICAL ACUTE OBSERVATION HR,3070008,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,,,,,Other,Not Separately reimbursable,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
OBS RM PER 1 HR 7T,3071010,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
HYDRATION INFUSION INITIAL HR,3071020,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3071021,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3071022,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3071023,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3071024,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3071025,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,,,,,Other,Not Separately reimbursable,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3071026,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3071027,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3071028,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3071029,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,76.95,
Immunization administration by a medical assistant or nurse,3071038,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
8T CARDIOVASCULAR OBSERVATION HR,3080008,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,,,,,Other,Not Separately reimbursable,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
OBSV RM PER 1 HR 8T,3081010,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
CARDIOVERSION,3083085,CDM,480,RC,92960,HCPCS,Outpatient,,,1452,871.2,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges,1089,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1110.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,653.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,696.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,1892.75,
HYDRATION INFUSION INITIAL HR,3086360,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3086361,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3086365,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3086366,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3086367,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3086368,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,,,,,Other,Not Separately reimbursable,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3086369,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3086370,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3086371,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3086372,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,76.95,
Immunization administration by a medical assistant or nurse,3086378,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
10 T OBS ROOM CRISIS UNIT,3100007,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
HEALTH AND BEHAVIORAL ASSESSMENT,3100008,CDM,914,RC,96150,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,146.68,
HEALTH AND BEHAVIORAL ASSESSMENT PHONE,3100012,CDM,914,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Collection of venous blood by venipuncture,3100013,CDM,300,RC,36415,HCPCS,Outpatient,,,18.36,11.02,,30.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,12.85,70,,,percent of total billed charges,70% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.99,350,,,Fee Schedule,350% of CMS OPPS Rate,8.74,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,230,,,Fee Schedule,230% of CMS OPPS Rate,8.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,30.33,
10T GEROPSYCH OBSERVATION HR,3100014,CDM,762,RC,G0378,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,2247,
ARCHER ADULT OBSERVATION HR,3100016,CDM,762,RC,G0378,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,2247,
ARCHER ADULT OBS ROOM CRISIS UNIT,3100102,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
INJECTION SQ OR IM,3106017,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
PNEUMOGRAM TRACING 12 HR,3118004,CDM,460,RC,94772,HCPCS,Outpatient,,,544.32,326.59,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,381.02,70,,,percent of total billed charges,70% of total billed charges,408.24,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,435.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,416.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,93.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,244.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,381.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,261.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,489.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,85.29,1555.77,
LTAC OBSERVATION HR,3203205,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,,,,,Other,Not Separately reimbursable,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
HEALTH AND BEHAVIORAL ASSESSMENT ADULT,3240008,CDM,914,RC,96150,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,146.68,
HEALTH AND BEHAVIORAL ASSESSMENT ADOL,3240009,CDM,914,RC,96150,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,146.68,
INJECTION SQ OR IM,3240116,CDM,510,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
ON-BODY INJECTOR APLCTN FOR TIMED SQ INJ,3240118,CDM,510,RC,96377,HCPCS,Outpatient,,,261,156.6,,136.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.75,75,,,percent of total billed charges,75% of total billed charges,69.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,234.9,
OUTPATIENT VISIT NEW BRIEF,3240125,CDM,510,RC,99201,HCPCS,Outpatient,,,117.37,70.42,,,,,,Other,Not Separately reimbursable,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,105.63,
Outpatient visit of established patient not requiring a physician,3240130,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,105.63,
CHEMO NON-HORMO ANTINEO INJ SQ/ IM,3240140,CDM,331,RC,96401,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
CHEMO HORMO ANTINEO INJ SQ/ IM,3240141,CDM,331,RC,96402,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
CHEMO INITIAL IV PUSH OR IVPB <= 15 MIN,3240142,CDM,331,RC,96409,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,77.88,664.77,
CHEMO ADDL IVP OR IV <=15 MIN SAME/DIFFR,3240143,CDM,331,RC,96411,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
CHEMO IV INITIAL HR >15 MIN <= 1HR,3240144,CDM,335,RC,96413,HCPCS,Outpatient,,,838,502.8,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,586.6,70,,,percent of total billed charges,70% of total billed charges,628.5,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,641.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,377.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,586.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,586.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,402.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,754.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,1070.43,
Chemotherapy infusion-each additional hour,3240145,CDM,335,RC,96415,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,25.7,400,
Chemotherapy infusion-additional IV pushes of the same medication,3240146,CDM,335,RC,96417,HCPCS,Outpatient,,,294.8,176.88,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.36,70,,,percent of total billed charges,70% of total billed charges,221.1,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,235.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,225.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,132.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,206.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,141.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,265.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,400,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3240147,CDM,510,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3240148,CDM,510,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,136.34,
HYDRATION INFUSION INITIAL HR,3240149,CDM,761,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3240150,CDM,761,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,136.34,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3240151,CDM,761,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3240152,CDM,761,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,148.5,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3240153,CDM,761,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,247.5,
CONCURRENT NONCHEMO INFUSION ADDL HR,3240154,CDM,761,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,,,,,Other,Not Separately reimbursable,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,57.92,
IRRIG DRUG DELIVERY DEVIC,3240156,CDM,510,RC,96523,HCPCS,Outpatient,,,149,89.4,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.75,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,184.98,
REFILL AND MAINT PORTABLE PUMP,3240157,CDM,761,RC,96521,HCPCS,Outpatient,,,393.2,235.92,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,294.9,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,314.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,300.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,176.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,275.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,235.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,188.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,353.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,61.61,664.77,
PROLONGED CHEMO ADMIN VIA PORT IMPL PUMP,3240158,CDM,761,RC,96416,HCPCS,Outpatient,,,838,502.8,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,628.5,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,641.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,377.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,586.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,586.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,402.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,754.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,131.31,1070.43,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3240159,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,76.95,
BLOOD DRAW FROM IMPLNTBL VENOUS DEVICE,3246591,CDM,761,RC,36591,HCPCS,Outpatient,,,112,67.2,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,84,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,85.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,53.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,100.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,373.66,
BLOOD DRAW FROM CENTRL OR PERIPHRL CATH,3246592,CDM,761,RC,36592,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
AMBULATORY ONCOLOGY - PRODUCTIVITY ONLY,3249999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
4T SURGICAL ACUTE OBSERVATION HR,3260006,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
HYDRATION INFUSION INITIAL HR,3260010,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3260011,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3260012,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3260014,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3260015,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,,,,,Other,Not Separately reimbursable,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3260016,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3260017,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3260018,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3260019,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,76.95,
Immunization administration by a medical assistant or nurse,3260023,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
"Psychotherapy, 30 min",3310010,CDM,919,RC,90832,HCPCS,Outpatient,,,356,213.6,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,267,75,,,percent of total billed charges,75% of total billed charges,267,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,272.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,160.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,170.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,320.4,
"Psychotherapy, 30 min",3310011,CDM,914,RC,90832,HCPCS,Outpatient,,,175.5,105.3,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.63,75,,,percent of total billed charges,75% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,134.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,157.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,268.22,
"Psychotherapy, 45 min",3310012,CDM,919,RC,90834,HCPCS,Outpatient,,,356,213.6,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,267,75,,,percent of total billed charges,75% of total billed charges,267,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,272.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,160.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,170.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,320.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,320.4,
"Psychotherapy, 45 min",3310013,CDM,914,RC,90834,HCPCS,Outpatient,,,245.5,147.3,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.13,75,,,percent of total billed charges,75% of total billed charges,184.13,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,196.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,187.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,110.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,171.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,171.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,117.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,220.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,110.48,268.22,
"Family psychotherapy, not including patient, 50 min",3310014,CDM,916,RC,90846,HCPCS,Outpatient,,,280,168,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,210,75,,,percent of total billed charges,75% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,126,268.22,
"Family psychotherapy, including patient, 50 min",3310015,CDM,916,RC,90847,HCPCS,Outpatient,,,280,168,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,210,75,,,percent of total billed charges,75% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,126,268.22,
Group psychotherapy,3310020,CDM,915,RC,90853,HCPCS,Outpatient,,,274,164.4,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.5,75,,,percent of total billed charges,75% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,209.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,246.6,
MRI of abdomen without dye,3330032,CDM,610,RC,74181,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI of brain stem without dye,3330034,CDM,610,RC,70551,HCPCS,Outpatient,,,1746,1047.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1571.4,
MRI scan of brain before and after contrast,3330035,CDM,610,RC,70553,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI BRAIN BRAIN STEM W CO,3330036,CDM,610,RC,70552,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI CERVIAL SPINE W CONTR,3330037,CDM,610,RC,72142,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI of the neck or spine without dye,3330038,CDM,610,RC,72141,HCPCS,Outpatient,,,1746,1047.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1571.4,
MRI of neck/spine with and without dye,3330039,CDM,610,RC,72156,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI ORBIT FACE NECK W O,3330040,CDM,610,RC,70540,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI LOW EXT NO JT W WO,3330041,CDM,610,RC,73720,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRI of lower extremity joint (knee/ankle) without dye,3330042,CDM,610,RC,73721,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI LUMBAR SPINE W CONTRA,3330043,CDM,610,RC,72149,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI scan of lower spinal canal,3330044,CDM,610,RC,72148,HCPCS,Outpatient,,,1746,1047.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1571.4,
MRI of lower back with and without dye,3330045,CDM,610,RC,72158,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI of chest and spine without dye,3330048,CDM,610,RC,72146,HCPCS,Outpatient,,,1746,1047.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1571.4,
MRI of chest and spine with and without dye,3330049,CDM,610,RC,72157,HCPCS,Outpatient,,,2027.5,1216.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1419.25,70,,,percent of total billed charges,70% of total billed charges,1520.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1622,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1551.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,349.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,912.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1216.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1419.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,973.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,317.71,1824.75,
MRI UP EXT NO JOINT W WO,3330050,CDM,610,RC,73220,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRI of upper extremity without dye,3330051,CDM,610,RC,73221,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRA ABDOMEN,3330053,CDM,610,RC,C8902,HCPCS,Outpatient,,,1746,1047.6,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,273.6,1571.4,
MRA CHEST,3330054,CDM,610,RC,71555,HCPCS,Outpatient,,,1800,1080,,324,18,,,percent of total billed charges,pays at 18% of total charges,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,754.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1260,70,,,percent of total billed charges,70% of total billed charges,1350,75,,,percent of total billed charges,75% of total billed charges,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1377,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,310.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1437,100,,,Case rate,Pays based on per visit ,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1620,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.06,1800,
MRA LOWER EXTREMITY,3330056,CDM,610,RC,C8914,HCPCS,Outpatient,,,1746,1047.6,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,273.6,1571.4,
MRI ORBIT FACE NECK W WO,3330061,CDM,610,RC,70543,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRA HEAD WO CONTRAST,3330062,CDM,610,RC,70544,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRA NECK W/O CONTRAST,3330063,CDM,610,RC,70547,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRA NECK W CONTRAST,3330064,CDM,610,RC,70548,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRA NECK W /WO CONT,3330065,CDM,610,RC,70549,HCPCS,Outpatient,,,1932,1159.2,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1352.4,70,,,percent of total billed charges,70% of total billed charges,1449,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1545.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1477.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,332.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,869.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1352.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1159.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1352.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,927.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1738.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,302.74,1738.8,
MRI of pelvis without dye,3330066,CDM,610,RC,72195,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI of pelvis before and after dye,3330067,CDM,610,RC,72197,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRI UP EXTREM NO JT W/O,3330069,CDM,610,RC,73218,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI ANY JT UP EXT W/WO,3330070,CDM,610,RC,73223,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRI of leg without dye,3330071,CDM,610,RC,73718,HCPCS,Outpatient,,,1471,882.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1029.7,70,,,percent of total billed charges,70% of total billed charges,1103.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1125.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,661.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1029.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,706.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1323.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI of lower extremity joint (knee/ankle) with and without dye,3330072,CDM,610,RC,73723,HCPCS,Outpatient,,,1707.5,1024.5,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1195.25,70,,,percent of total billed charges,70% of total billed charges,1280.63,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1366,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1306.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1195.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.57,1536.75,
MRI of abdomen without and with dye,3330073,CDM,610,RC,74183,HCPCS,Outpatient,,,2125.2,1275.12,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1487.64,70,,,percent of total billed charges,70% of total billed charges,1593.9,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1700.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1625.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,366.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,956.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1487.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1275.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1487.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1912.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,333.02,1912.68,
MRI-LEXTREM NO JNT W CONTRAST,3333719,CDM,610,RC,73719,HCPCS,Outpatient,,,1707,1024.2,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1194.9,70,,,percent of total billed charges,70% of total billed charges,1280.25,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1365.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1305.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,768.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,819.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,267.49,1536.3,
MRI of lower extremity joint (knee/ankle) with dye,3333722,CDM,610,RC,73722,HCPCS,Outpatient,,,1707,1024.2,,2383.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1194.9,70,,,percent of total billed charges,70% of total billed charges,1280.25,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1365.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.94,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1305.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,768.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,819.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,267.49,2383.88,
MRI BREAST W/WO UNILAT AMRI,3337046,CDM,610,RC,77046,HCPCS,Outpatient,,,,,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,470.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
MRI BREAST W/O UNILAT AMRI,3337046,CDM,610,RC,77046,HCPCS,Outpatient,,,2000,1200,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,470.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1800,
"Magnetic resonance imaging, breasts, without contrast material; bilateral",3337047,CDM,610,RC,77047,HCPCS,Outpatient,,,,,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,470.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1437,
"Magnetic resonance imaging, breasts, without contrast material; bilateral",3337047,CDM,610,RC,77047,HCPCS,Outpatient,,,2000,1200,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,470.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1437,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,1800,
MRI BREAST W/WO UNILAT AMRI,3337058,CDM,610,RC,77048,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1437,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.49,1437,
MRI BREAST W/WO BILAT AMRI,3337059,CDM,610,RC,77049,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1437,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.98,1437,
MRI BREAST W/WO BILAT LCMH,3337059,CDM,610,RC,77049,HCPCS,Outpatient,,,2000,1200,,360,18,,,percent of total billed charges,pays at 18% of total charges,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,712.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1437,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.4,2000,
6T POST PARTUM OBSERVATION HR,3400008,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
WOMENS SPECIALTY ROOM OBSERVATION HR,3400009,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
OBSERVATION PER HOUR WS,3401010,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
HYDRATION INFUSION INITIAL HR,3401212,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3401214,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3401215,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3401216,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3401217,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3401218,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,3401219,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3401220,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3401221,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3401222,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
Immunization administration by a medical assistant or nurse,3401228,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
OUTPATIENT VISIT NEW BRIEF,3440201,CDM,514,RC,99201,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,117.37,
"New patient office or other outpatient visit, typically 10 minutes",3440202,CDM,514,RC,99202,HCPCS,Outpatient,,,152,91.2,,27.36,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,152,
"New patient office or other outpatient visit, typically 30 min",3440203,CDM,514,RC,99203,HCPCS,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,228,
"New patient office of other outpatient visit, typically 45 min",3440204,CDM,514,RC,99204,HCPCS,Outpatient,,,389,233.4,,70.02,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,70.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.75,75,,,percent of total billed charges,75% of total billed charges,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,389,
"New patient office of other outpatient visit, typically 60 min",3440205,CDM,514,RC,99205,HCPCS,Outpatient,,,306.04,183.62,,55.09,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,55.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.53,75,,,percent of total billed charges,75% of total billed charges,153.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.09,306.04,
OB CARE CLINIC PRODUCTIVITY ONLY,3440206,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Outpatient visit of established patient not requiring a physician,3440211,CDM,514,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,3440212,CDM,514,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",3440213,CDM,514,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",3440214,CDM,514,RC,99214,HCPCS,Outpatient,,,236,141.6,,42.48,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177,75,,,percent of total billed charges,75% of total billed charges,118,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,165.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,236,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,212.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.48,236,
"Established patient office or other outpatient, visit typically 40 minutes",3440215,CDM,514,RC,99215,HCPCS,Outpatient,,,235,141,,42.3,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.25,75,,,percent of total billed charges,75% of total billed charges,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,211.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.3,235,
A lab test to screen for evidence of vaginal infection,3440306,CDM,300,RC,87210,HCPCS,Outpatient,,,17,10.2,,20.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,10.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.37,350,,,Fee Schedule,350% of CMS OPPS Rate,5.93,102,,,Fee Schedule,102% of CMS OPPS Rate,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of UHC Fee Schedule,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.38,230,,,Fee Schedule,230% of CMS OPPS Rate,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,20.6,
INJECTION SQ OR IM,3446372,CDM,514,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
SET SMALL BORE EXT W 0.2 MICRON FILTER,3501000,CDM,272,RC,,,Outpatient,,,10.5,6.3,,1.89,18,,,percent of total billed charges,pays at 18% of total charges,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.25,50,,,percent of total billed charges,pays at 50% of total billed charges,7.35,70,,,percent of total billed charges,70% of total billed charges,7.88,75,,,percent of total billed charges,75% of total billed charges,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,10.5,
INTUBATION ENDOTRACHEAL,3501500,CDM,761,RC,31500,HCPCS,Outpatient,,,584,350.4,,668.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,363.94,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,438,75,,,percent of total billed charges,75% of total billed charges,340.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.27,350,,,Fee Schedule,350% of CMS OPPS Rate,192.71,103,,,Fee Schedule,103% of CMS OPPS Rate,446.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,262.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,408.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,350.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,408.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,434.54,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,525.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,91.51,668.83,
Outpatient visit of established patient not requiring a physician,3502000,CDM,761,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.27,123,
KIT NEONATE COOLING,3503618,CDM,272,RC,,,Outpatient,,,154.5,92.7,,27.81,18,,,percent of total billed charges,pays at 18% of total charges,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.25,50,,,percent of total billed charges,pays at 50% of total billed charges,108.15,70,,,percent of total billed charges,70% of total billed charges,115.88,75,,,percent of total billed charges,75% of total billed charges,77.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,154.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,139.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.21,154.5,
GAVAGE OR LAVAGE SET UP,3507278,CDM,271,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
ADMIT PRODUCTIVITY ONLY,3600013,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
POST PROCEDURE PRODUCTIVITY ONLY,3600014,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PHONE ADMIT PRODUCTIVITY ONLY,3600015,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PRE ADMIT PRODUCTIVITY ONLY,3600016,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
CARDIOVERSION,3600017,CDM,360,RC,92960,HCPCS,Outpatient,,,1452,871.2,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges,1089,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1110.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,653.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,696.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,1892.75,
SAFEGUARD DSG,3600018,CDM,272,RC,,,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,50,,,percent of total billed charges,pays at 50% of total billed charges,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,125,
PSEUDOANEURYSM COMPRES W US,3600019,CDM,710,RC,76936,HCPCS,Outpatient,,,279.92,167.95,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.94,70,,,percent of total billed charges,70% of total billed charges,209.94,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,223.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,214.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,125.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,195.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,134.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,251.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.86,901.29,
INJECT PSEUDOANEURYSM,3600020,CDM,710,RC,36002,HCPCS,Outpatient,,,736,441.6,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,515.2,70,,,percent of total billed charges,70% of total billed charges,552,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,588.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,563.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,331.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,353.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,662.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,115.33,1861.73,
STERI STRIPS ALL SIZES,3600472,CDM,272,RC,,,Outpatient,,,11.5,6.9,,2.07,18,,,percent of total billed charges,pays at 18% of total charges,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.75,50,,,percent of total billed charges,pays at 50% of total billed charges,8.05,70,,,percent of total billed charges,70% of total billed charges,8.63,75,,,percent of total billed charges,75% of total billed charges,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,11.5,
HOLDER STERILE DISP,3600473,CDM,272,RC,,,Outpatient,,,27,16.2,,4.86,18,,,percent of total billed charges,pays at 18% of total charges,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,50,,,percent of total billed charges,pays at 50% of total billed charges,18.9,70,,,percent of total billed charges,70% of total billed charges,20.25,75,,,percent of total billed charges,75% of total billed charges,13.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.23,27,
RETRACTOR ATRIAL LIFT DISP,3600475,CDM,272,RC,,,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.5,50,,,percent of total billed charges,pays at 50% of total billed charges,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
SPRINGCLIP FOGARTY BULLDOG,3600478,CDM,272,RC,,,Outpatient,,,26,15.6,,4.68,18,,,percent of total billed charges,pays at 18% of total charges,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13,50,,,percent of total billed charges,pays at 50% of total billed charges,18.2,70,,,percent of total billed charges,70% of total billed charges,19.5,75,,,percent of total billed charges,75% of total billed charges,13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,26,
INTRODUCER VALVED AIRGUARD,3600480,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
PATCH CAROTID TAPERED,3600485,CDM,278,RC,C1768,HCPCS,Outpatient,,,179.86,107.92,,32.37,18,,,percent of total billed charges,pays at 18% of total charges,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.9,70,,,percent of total billed charges,70% of total billed charges,134.9,75,,,percent of total billed charges,75% of total billed charges,89.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,179.86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,179.86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.18,179.86,
WIRE PACING CARDIAC TEMP,3600490,CDM,272,RC,,,Outpatient,,,37,22.2,,6.66,18,,,percent of total billed charges,pays at 18% of total charges,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.5,50,,,percent of total billed charges,pays at 50% of total billed charges,25.9,70,,,percent of total billed charges,70% of total billed charges,27.75,75,,,percent of total billed charges,75% of total billed charges,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,33.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,37,
ORGANIZER SUTURE BELT DISP,3600495,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
SURGERY PROCEDURE BEDSIDE,3602000,CDM,760,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.18,2239,
PERFUSION FEE CELL SAVER,3602012,CDM,300,RC,86891,HCPCS,Outpatient,,,3244.5,1946.7,,2498.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1102.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2271.15,70,,,percent of total billed charges,70% of total billed charges,2433.38,75,,,percent of total billed charges,75% of total billed charges,1270.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2595.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.73,350,,,Fee Schedule,350% of CMS OPPS Rate,720.04,103,,,Fee Schedule,103% of CMS OPPS Rate,2482.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1460.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2271.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1946.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,486.86,100,,,Fee Schedule,100% of UHC Fee Schedule,2271.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2920.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,13.45,2920.05,
PERFUSION FEE EACH HOUR,3602016,CDM,949,RC,99190,HCPCS,Outpatient,,,4866.48,2919.89,,4866.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4866.48,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4866.48,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2433.24,50,,,percent of total billed charges,pays at 50% of total billed charges,3406.54,70,,,percent of total billed charges,70% of total billed charges,3649.86,75,,,percent of total billed charges,75% of total billed charges,4866.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4866.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4866.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,2189.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3406.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2919.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,3406.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2335.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4379.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4866.48,100,,,Fee Schedule,100% of CMS OPPS Rate,174,4866.48,
PERFUSION FEE - 45 MIN,3602017,CDM,949,RC,99191,HCPCS,Outpatient,,,1075.2,645.12,,1075.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1075.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1075.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,537.6,50,,,percent of total billed charges,pays at 50% of total billed charges,752.64,70,,,percent of total billed charges,70% of total billed charges,806.4,75,,,percent of total billed charges,75% of total billed charges,1075.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,860.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1075.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1075.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,822.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,483.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,752.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,752.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,967.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.2,100,,,Fee Schedule,100% of CMS OPPS Rate,174,1075.2,
PERFUSION FEE - 30 MIN,3602018,CDM,949,RC,99192,HCPCS,Outpatient,,,644.76,386.86,,644.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,644.76,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,644.76,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,322.38,50,,,percent of total billed charges,pays at 50% of total billed charges,451.33,70,,,percent of total billed charges,70% of total billed charges,483.57,75,,,percent of total billed charges,75% of total billed charges,644.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,515.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,644.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,644.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,493.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,290.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,451.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,451.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,309.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,580.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,644.76,100,,,Fee Schedule,100% of CMS OPPS Rate,174,644.76,
CHG TIME SURG X 1/4 HR.,3607110,CDM,360,RC,,,Outpatient,,,1127.25,676.35,,202.91,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,202.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,563.63,50,,,percent of total billed charges,pays at 50% of total billed charges,789.08,70,,,percent of total billed charges,70% of total billed charges,845.44,75,,,percent of total billed charges,75% of total billed charges,563.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,901.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,862.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,789.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,676.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1127.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1014.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.91,1127.25,
CHG SURG LVL1 1MIN INC,3607111,CDM,360,RC,,,Outpatient,,,85,51,,15.3,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,15.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.5,50,,,percent of total billed charges,pays at 50% of total billed charges,59.5,70,,,percent of total billed charges,70% of total billed charges,63.75,75,,,percent of total billed charges,75% of total billed charges,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,85,
CHG SURG LVL2 1MIN INC,3607112,CDM,360,RC,,,Outpatient,,,115,69,,20.7,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.5,50,,,percent of total billed charges,pays at 50% of total billed charges,80.5,70,,,percent of total billed charges,70% of total billed charges,86.25,75,,,percent of total billed charges,75% of total billed charges,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,115,
CHG SURG LVL3 1MIN INC,3607113,CDM,360,RC,,,Outpatient,,,118,70.8,,21.24,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,21.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59,50,,,percent of total billed charges,pays at 50% of total billed charges,82.6,70,,,percent of total billed charges,70% of total billed charges,88.5,75,,,percent of total billed charges,75% of total billed charges,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,118,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.24,118,
CHG SURG LVL4 1MIN INC,3607114,CDM,360,RC,,,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,50,,,percent of total billed charges,pays at 50% of total billed charges,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,125,
CHG SURG LVL5 1MIN INC,3607115,CDM,360,RC,,,Outpatient,,,130,78,,23.4,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,23.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65,50,,,percent of total billed charges,pays at 50% of total billed charges,91,70,,,percent of total billed charges,70% of total billed charges,97.5,75,,,percent of total billed charges,75% of total billed charges,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,130,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,130,
CHG SURG LVL6 1MIN INC,3607116,CDM,360,RC,,,Outpatient,,,195,117,,35.1,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,35.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.5,50,,,percent of total billed charges,pays at 50% of total billed charges,136.5,70,,,percent of total billed charges,70% of total billed charges,146.25,75,,,percent of total billed charges,75% of total billed charges,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,136.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,195,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.1,195,
CHG SURG LVL7 1MIN INC,3607117,CDM,360,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,205,
CHG SURG CASE SETUP,3607120,CDM,360,RC,,,Outpatient,,,469.75,281.85,,84.56,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,84.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.88,50,,,percent of total billed charges,pays at 50% of total billed charges,328.83,70,,,percent of total billed charges,70% of total billed charges,352.31,75,,,percent of total billed charges,75% of total billed charges,234.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,375.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,281.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,359.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,328.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,281.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,469.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,422.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.56,469.75,
OR LEVEL 1 INI 15 MIN,3607121,CDM,360,RC,,,Outpatient,,,2141,1284.6,,385.38,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,385.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1070.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1498.7,70,,,percent of total billed charges,70% of total billed charges,1605.75,75,,,percent of total billed charges,75% of total billed charges,1070.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1712.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1284.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1637.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1498.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1284.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2141,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1926.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.38,2141,
OR LEVEL 2 INI 15 MIN,3607122,CDM,360,RC,,,Outpatient,,,4786,2871.6,,861.48,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,861.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2393,50,,,percent of total billed charges,pays at 50% of total billed charges,3350.2,70,,,percent of total billed charges,70% of total billed charges,3589.5,75,,,percent of total billed charges,75% of total billed charges,2393,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3828.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2871.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3661.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2153.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3350.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2871.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3350.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2297.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4786,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4307.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,861.48,4786,
OR LEVEL 3 INI 15 MIN,3607123,CDM,360,RC,,,Outpatient,,,5815,3489,,1046.7,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,1046.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2907.5,50,,,percent of total billed charges,pays at 50% of total billed charges,4070.5,70,,,percent of total billed charges,70% of total billed charges,4361.25,75,,,percent of total billed charges,75% of total billed charges,2907.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3489,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4448.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2616.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4070.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3489,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4070.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2791.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5815,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5233.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.7,5815,
OR LEVEL 4 INI 15 MIN,3607124,CDM,360,RC,,,Outpatient,,,6024,3614.4,,1084.32,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,1084.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3012,50,,,percent of total billed charges,pays at 50% of total billed charges,4216.8,70,,,percent of total billed charges,70% of total billed charges,4518,75,,,percent of total billed charges,75% of total billed charges,3012,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3614.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4608.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2710.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4216.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3614.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4216.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2891.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6024,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5421.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1084.32,6024,
OR LEVEL 5 INI 15 MIN,3607125,CDM,360,RC,,,Outpatient,,,7494,4496.4,,1348.92,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,1348.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3747,50,,,percent of total billed charges,pays at 50% of total billed charges,5245.8,70,,,percent of total billed charges,70% of total billed charges,5620.5,75,,,percent of total billed charges,75% of total billed charges,3747,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5995.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4496.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5732.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3372.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5245.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4496.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5245.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3597.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7494,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6744.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1348.92,7494,
OR LEVEL 6 INI 15 MIN,3607126,CDM,360,RC,,,Outpatient,,,10354,6212.4,,1863.72,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,1863.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5177,50,,,percent of total billed charges,pays at 50% of total billed charges,7247.8,70,,,percent of total billed charges,70% of total billed charges,7765.5,75,,,percent of total billed charges,75% of total billed charges,5177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7920.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4969.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10354,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9318.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1863.72,10354,
OR LEVEL 7 INI 15 MIN,3607127,CDM,360,RC,,,Outpatient,,,11326,6795.6,,2038.68,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,2038.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5663,50,,,percent of total billed charges,pays at 50% of total billed charges,7928.2,70,,,percent of total billed charges,70% of total billed charges,8494.5,75,,,percent of total billed charges,75% of total billed charges,5663,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9060.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6795.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8664.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5096.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7928.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6795.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7928.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5436.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11326,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10193.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.68,11326,
IMPLANT TOE,3607130,CDM,278,RC,C1776,HCPCS,Outpatient,,,1723.8,1034.28,,310.28,18,,,percent of total billed charges,pays at 18% of total charges,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.66,70,,,percent of total billed charges,70% of total billed charges,1292.85,75,,,percent of total billed charges,75% of total billed charges,861.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1379.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1034.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1723.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,297.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1206.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1034.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1723.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1723.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,270.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.12,1723.8,
KIT AUTOGRAFTING MICRO,3607132,CDM,272,RC,,,Outpatient,,,1038.7,623.22,,186.97,18,,,percent of total billed charges,pays at 18% of total charges,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,519.35,50,,,percent of total billed charges,pays at 50% of total billed charges,727.09,70,,,percent of total billed charges,70% of total billed charges,779.03,75,,,percent of total billed charges,75% of total billed charges,519.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,830.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,623.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,794.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,727.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,623.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1038.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,934.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.76,1038.7,
RECOVERY EXTND SDS 1MIN,3609600,CDM,710,RC,,,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.5,50,,,percent of total billed charges,pays at 50% of total billed charges,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,75,
BURN MATRIX WASTE PER SQ CM,3610003,CDM,636,RC,Q4166,HCPCS,Outpatient,,,39.34,23.6,,7.08,18,,,percent of total billed charges,pays at 18% of total charges,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.67,50,,,percent of total billed charges,pays at 50% of total billed charges,27.54,70,,,percent of total billed charges,70% of total billed charges,29.51,75,,,percent of total billed charges,75% of total billed charges,19.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,39.34,
GRAFT VASCULAR,3610004,CDM,278,RC,C1768,HCPCS,Outpatient,,,475.77,285.46,,85.64,18,,,percent of total billed charges,pays at 18% of total charges,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.04,70,,,percent of total billed charges,70% of total billed charges,356.83,75,,,percent of total billed charges,75% of total billed charges,237.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,380.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,475.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,333.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,285.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,475.77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,475.77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.55,475.77,
COMPONENT ULNA,3610005,CDM,278,RC,C1776,HCPCS,Outpatient,,,3150,1890,,567,18,,,percent of total billed charges,pays at 18% of total charges,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,567,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,70,,,percent of total billed charges,70% of total billed charges,2362.5,75,,,percent of total billed charges,75% of total billed charges,1575,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1890,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3150,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,542.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2205,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1890,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2205,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1512,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,493.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.61,3150,
SYS WOUND EXTRACTION,3610007,CDM,272,RC,,,Outpatient,,,423,253.8,,76.14,18,,,percent of total billed charges,pays at 18% of total charges,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.5,50,,,percent of total billed charges,pays at 50% of total billed charges,296.1,70,,,percent of total billed charges,70% of total billed charges,317.25,75,,,percent of total billed charges,75% of total billed charges,211.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,423,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.28,423,
COLLAGEN WRAP NERVE PER 0.5CM,3610009,CDM,278,RC,C9361,HCPCS,Outpatient,,,70,42,,12.6,18,,,percent of total billed charges,pays at 18% of total charges,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,70,
WASTE WRAP NERVE PER 0.5CM,3610010,CDM,278,RC,C9361,HCPCS,Outpatient,,,70,42,,12.6,18,,,percent of total billed charges,pays at 18% of total charges,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,70,
TENDON HUNTER ACTIVE,3610011,CDM,278,RC,C1762,HCPCS,Outpatient,,,2240,1344,,403.2,18,,,percent of total billed charges,pays at 18% of total charges,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568,70,,,percent of total billed charges,70% of total billed charges,1680,75,,,percent of total billed charges,75% of total billed charges,1120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1344,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2240,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,385.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1568,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1344,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.01,2240,
RING FIXATION,3610012,CDM,272,RC,,,Outpatient,,,2523,1513.8,,454.14,18,,,percent of total billed charges,pays at 18% of total charges,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1261.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1766.1,70,,,percent of total billed charges,70% of total billed charges,1892.25,75,,,percent of total billed charges,75% of total billed charges,1261.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2018.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1513.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1930.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1766.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1513.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1766.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2523,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2270.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.35,2523,
RING FIXATION HALF,3610013,CDM,272,RC,,,Outpatient,,,935.85,561.51,,168.45,18,,,percent of total billed charges,pays at 18% of total charges,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,467.93,50,,,percent of total billed charges,pays at 50% of total billed charges,655.1,70,,,percent of total billed charges,70% of total billed charges,701.89,75,,,percent of total billed charges,75% of total billed charges,467.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,748.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,561.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,715.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,655.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,561.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,935.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,842.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.65,935.85,
PLATE BRIDGING FIXATION,3610014,CDM,272,RC,,,Outpatient,,,2724.05,1634.43,,490.33,18,,,percent of total billed charges,pays at 18% of total charges,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,490.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1362.03,50,,,percent of total billed charges,pays at 50% of total billed charges,1906.84,70,,,percent of total billed charges,70% of total billed charges,2043.04,75,,,percent of total billed charges,75% of total billed charges,1362.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2179.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1634.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2083.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1225.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1906.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1634.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1906.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1307.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2724.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2451.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.86,2724.05,
BOLT FIXATION,3610015,CDM,272,RC,,,Outpatient,,,189,113.4,,34.02,18,,,percent of total billed charges,pays at 18% of total charges,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,50,,,percent of total billed charges,pays at 50% of total billed charges,132.3,70,,,percent of total billed charges,70% of total billed charges,141.75,75,,,percent of total billed charges,75% of total billed charges,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,189,
STRUT QUICK ADJ FIXATION,3610016,CDM,272,RC,,,Outpatient,,,2423.15,1453.89,,436.17,18,,,percent of total billed charges,pays at 18% of total charges,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1211.58,50,,,percent of total billed charges,pays at 50% of total billed charges,1696.21,70,,,percent of total billed charges,70% of total billed charges,1817.36,75,,,percent of total billed charges,75% of total billed charges,1211.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1938.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1453.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1853.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1696.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1453.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1696.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2423.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2180.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.71,2423.15,
SET STRUT ID BAND,3610017,CDM,272,RC,,,Outpatient,,,819,491.4,,147.42,18,,,percent of total billed charges,pays at 18% of total charges,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.5,50,,,percent of total billed charges,pays at 50% of total billed charges,573.3,70,,,percent of total billed charges,70% of total billed charges,614.25,75,,,percent of total billed charges,75% of total billed charges,409.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,655.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,626.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,819,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,737.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.34,819,
WIRE POST FIXATION,3610018,CDM,272,RC,,,Outpatient,,,499,299.4,,89.82,18,,,percent of total billed charges,pays at 18% of total charges,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.5,50,,,percent of total billed charges,pays at 50% of total billed charges,349.3,70,,,percent of total billed charges,70% of total billed charges,374.25,75,,,percent of total billed charges,75% of total billed charges,249.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,399.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,381.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,349.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,299.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,499,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,449.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.19,499,
PLATE CONNECT FIXATION,3610020,CDM,272,RC,,,Outpatient,,,233.1,139.86,,41.96,18,,,percent of total billed charges,pays at 18% of total charges,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.55,50,,,percent of total billed charges,pays at 50% of total billed charges,163.17,70,,,percent of total billed charges,70% of total billed charges,174.83,75,,,percent of total billed charges,75% of total billed charges,116.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,233.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,209.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.53,233.1,
NUT SQUARE FIXATION,3610022,CDM,272,RC,,,Outpatient,,,196.55,117.93,,35.38,18,,,percent of total billed charges,pays at 18% of total charges,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.28,50,,,percent of total billed charges,pays at 50% of total billed charges,137.59,70,,,percent of total billed charges,70% of total billed charges,147.41,75,,,percent of total billed charges,75% of total billed charges,98.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,137.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,196.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,176.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.8,196.55,
WASHER SPACING FIXATION,3610023,CDM,272,RC,,,Outpatient,,,30.25,18.15,,5.45,18,,,percent of total billed charges,pays at 18% of total charges,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.13,50,,,percent of total billed charges,pays at 50% of total billed charges,21.18,70,,,percent of total billed charges,70% of total billed charges,22.69,75,,,percent of total billed charges,75% of total billed charges,15.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.74,30.25,
ROD THREADED FIXATION,3610024,CDM,272,RC,,,Outpatient,,,151.2,90.72,,27.22,18,,,percent of total billed charges,pays at 18% of total charges,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.6,50,,,percent of total billed charges,pays at 50% of total billed charges,105.84,70,,,percent of total billed charges,70% of total billed charges,113.4,75,,,percent of total billed charges,75% of total billed charges,75.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.69,151.2,
KIT FOOT PLATE SUPPORT,3610026,CDM,272,RC,,,Outpatient,,,1906.6,1143.96,,343.19,18,,,percent of total billed charges,pays at 18% of total charges,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,953.3,50,,,percent of total billed charges,pays at 50% of total billed charges,1334.62,70,,,percent of total billed charges,70% of total billed charges,1429.95,75,,,percent of total billed charges,75% of total billed charges,953.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1525.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1143.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1458.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1334.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1334.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1906.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1715.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.76,1906.6,
WIRE REDUCTION ORTHO,3610027,CDM,278,RC,C1713,HCPCS,Outpatient,,,460.8,276.48,,82.94,18,,,percent of total billed charges,pays at 18% of total charges,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.56,70,,,percent of total billed charges,70% of total billed charges,345.6,75,,,percent of total billed charges,75% of total billed charges,230.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,460.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,322.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,276.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,460.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,460.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.21,460.8,
HUMERAL HEAD,3610028,CDM,278,RC,C1716,HCPCS,Outpatient,,,1320,792,,816.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,230.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,660,50,,,percent of total billed charges,pays at 50% of total billed charges,924,70,,,percent of total billed charges,70% of total billed charges,990,75,,,percent of total billed charges,75% of total billed charges,415.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,807.62,350,,,Fee Schedule,350% of CMS OPPS Rate,235.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1320,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,227.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,594,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,924,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,792,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,924,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,530.72,100,,,Fee Schedule,100% of CMS OPPS Rate,633.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1320,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,100,,,Fee Schedule,100% of CMS OPPS Rate,206.84,1320,
SYS SURGICAL DEVICE,3610029,CDM,272,RC,,,Outpatient,,,2080,1248,,374.4,18,,,percent of total billed charges,pays at 18% of total charges,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1040,50,,,percent of total billed charges,pays at 50% of total billed charges,1456,70,,,percent of total billed charges,70% of total billed charges,1560,75,,,percent of total billed charges,75% of total billed charges,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1248,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1591.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1248,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,998.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1872,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.94,2080,
FORCEP EYE DISP,3610030,CDM,272,RC,,,Outpatient,,,151.34,90.8,,27.24,18,,,percent of total billed charges,pays at 18% of total charges,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.67,50,,,percent of total billed charges,pays at 50% of total billed charges,105.94,70,,,percent of total billed charges,70% of total billed charges,113.51,75,,,percent of total billed charges,75% of total billed charges,75.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.71,151.34,
MAGNET INTROCULAR,3610031,CDM,272,RC,,,Outpatient,,,151.34,90.8,,27.24,18,,,percent of total billed charges,pays at 18% of total charges,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.67,50,,,percent of total billed charges,pays at 50% of total billed charges,105.94,70,,,percent of total billed charges,70% of total billed charges,113.51,75,,,percent of total billed charges,75% of total billed charges,75.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.71,151.34,
GRAFT SPREADER,3610032,CDM,272,RC,,,Outpatient,,,697,418.2,,125.46,18,,,percent of total billed charges,pays at 18% of total charges,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.5,50,,,percent of total billed charges,pays at 50% of total billed charges,487.9,70,,,percent of total billed charges,70% of total billed charges,522.75,75,,,percent of total billed charges,75% of total billed charges,348.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,697,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.22,697,
ANCHOR TENDON TISSUETRAK,3610033,CDM,278,RC,C1713,HCPCS,Outpatient,,,1625,975,,292.5,18,,,percent of total billed charges,pays at 18% of total charges,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.5,70,,,percent of total billed charges,70% of total billed charges,1218.75,75,,,percent of total billed charges,75% of total billed charges,812.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,975,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1625,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,279.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,1625,
PROTECTOR-FOAM-HEADREST,3610041,CDM,270,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
SUTURE GORE TEX,3610045,CDM,272,RC,,,Outpatient,,,152.5,91.5,,27.45,18,,,percent of total billed charges,pays at 18% of total charges,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.25,50,,,percent of total billed charges,pays at 50% of total billed charges,106.75,70,,,percent of total billed charges,70% of total billed charges,114.38,75,,,percent of total billed charges,75% of total billed charges,76.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.9,152.5,
IMPLANT MEDIAL LIGAMENT BIOCOMPOSITE,3610046,CDM,278,RC,C1776,HCPCS,Outpatient,,,2762.5,1657.5,,497.25,18,,,percent of total billed charges,pays at 18% of total charges,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,497.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1933.75,70,,,percent of total billed charges,70% of total billed charges,2071.88,75,,,percent of total billed charges,75% of total billed charges,1381.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2210,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1657.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2762.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,475.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1243.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1933.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1657.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1933.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2762.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2762.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.88,2762.5,
DRIVER HELICAL,3610048,CDM,272,RC,,,Outpatient,,,1248,748.8,,224.64,18,,,percent of total billed charges,pays at 18% of total charges,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,624,50,,,percent of total billed charges,pays at 50% of total billed charges,873.6,70,,,percent of total billed charges,70% of total billed charges,936,75,,,percent of total billed charges,75% of total billed charges,624,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,954.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1123.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.56,1248,
CURETTE REVERSE,3610049,CDM,272,RC,,,Outpatient,,,1248,748.8,,224.64,18,,,percent of total billed charges,pays at 18% of total charges,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,624,50,,,percent of total billed charges,pays at 50% of total billed charges,873.6,70,,,percent of total billed charges,70% of total billed charges,936,75,,,percent of total billed charges,75% of total billed charges,624,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,954.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1123.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.56,1248,
BONE WAX,3610100,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
FEMORAL COMPONENT,3610125,CDM,278,RC,C1776,HCPCS,Outpatient,,,4699,2819.4,,845.82,18,,,percent of total billed charges,pays at 18% of total charges,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,845.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3289.3,70,,,percent of total billed charges,70% of total billed charges,3524.25,75,,,percent of total billed charges,75% of total billed charges,2349.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3759.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2819.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4699,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,809.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2114.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3289.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2819.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3289.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2255.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4699,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4699,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,736.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,736.33,4699,
CEMENT MOLD FEMORAL,3610126,CDM,272,RC,,,Outpatient,,,3554.2,2132.52,,639.76,18,,,percent of total billed charges,pays at 18% of total charges,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1777.1,50,,,percent of total billed charges,pays at 50% of total billed charges,2487.94,70,,,percent of total billed charges,70% of total billed charges,2665.65,75,,,percent of total billed charges,75% of total billed charges,1777.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2843.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2132.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2718.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1599.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2487.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2132.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2487.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1706.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3554.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3198.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,556.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.94,3554.2,
SUTURE CHROMIC 0,3610132,CDM,272,RC,,,Outpatient,,,19,11.4,,3.42,18,,,percent of total billed charges,pays at 18% of total charges,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,19,
DERMAHOOKS,3610137,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
PACK LAMINECTOMY,3610140,CDM,272,RC,,,Outpatient,,,416,249.6,,74.88,18,,,percent of total billed charges,pays at 18% of total charges,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208,50,,,percent of total billed charges,pays at 50% of total billed charges,291.2,70,,,percent of total billed charges,70% of total billed charges,312,75,,,percent of total billed charges,75% of total billed charges,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,374.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.19,416,
PACK TOTAL HIP,3610143,CDM,272,RC,,,Outpatient,,,354,212.4,,63.72,18,,,percent of total billed charges,pays at 18% of total charges,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177,50,,,percent of total billed charges,pays at 50% of total billed charges,247.8,70,,,percent of total billed charges,70% of total billed charges,265.5,75,,,percent of total billed charges,75% of total billed charges,177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,354,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,318.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.47,354,
SUTURE CHROMIC SUTUPAK,3610154,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SUTURE CHROMIC 1-0,3610160,CDM,272,RC,,,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
SUTURE CHROMIC CR,3610161,CDM,272,RC,,,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
SUTURE CHROMIC 2-0,3610174,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
KITTNER ENDOSCOPIC,3610188,CDM,272,RC,,,Outpatient,,,120,72,,21.6,18,,,percent of total billed charges,pays at 18% of total charges,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60,50,,,percent of total billed charges,pays at 50% of total billed charges,84,70,,,percent of total billed charges,70% of total billed charges,90,75,,,percent of total billed charges,75% of total billed charges,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,120,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,108,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.8,120,
SUTURE CHROMIC 3-0,3610208,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SEALANT PLEURAL,3610221,CDM,272,RC,C2615,HCPCS,Outpatient,,,1202.5,721.5,,216.45,18,,,percent of total billed charges,pays at 18% of total charges,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.75,70,,,percent of total billed charges,70% of total billed charges,901.88,75,,,percent of total billed charges,75% of total billed charges,601.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,962,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,721.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,919.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1202.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1082.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.43,1202.5,
SUTURE CHROMIC 4-0,3610222,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SPLINT ORTHOGLASS,3610227,CDM,272,RC,,,Outpatient,,,10.5,6.3,,1.89,18,,,percent of total billed charges,pays at 18% of total charges,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.25,50,,,percent of total billed charges,pays at 50% of total billed charges,7.35,70,,,percent of total billed charges,70% of total billed charges,7.88,75,,,percent of total billed charges,75% of total billed charges,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,10.5,
CONNECTOR BYPASS,3610243,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
SUTURE CHROMIC 5-0,3610244,CDM,272,RC,,,Outpatient,,,58,34.8,,10.44,18,,,percent of total billed charges,pays at 18% of total charges,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29,50,,,percent of total billed charges,pays at 50% of total billed charges,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,58,
SUTURE CHROMIC 6-0,3610246,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
FEMORAL STEM,3610250,CDM,278,RC,C1776,HCPCS,Outpatient,,,3768.5,2261.1,,678.33,18,,,percent of total billed charges,pays at 18% of total charges,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,678.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2637.95,70,,,percent of total billed charges,70% of total billed charges,2826.38,75,,,percent of total billed charges,75% of total billed charges,1884.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3014.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2261.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3768.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,649.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1695.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2637.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2261.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2637.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1808.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3768.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3768.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,590.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.52,3768.5,
HEART PUNCH,3610253,CDM,272,RC,,,Outpatient,,,113.5,68.1,,20.43,18,,,percent of total billed charges,pays at 18% of total charges,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.75,50,,,percent of total billed charges,pays at 50% of total billed charges,79.45,70,,,percent of total billed charges,70% of total billed charges,85.13,75,,,percent of total billed charges,75% of total billed charges,56.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,113.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,102.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.79,113.5,
SUTURE DERMAL,3610260,CDM,272,RC,,,Outpatient,,,72.5,43.5,,13.05,18,,,percent of total billed charges,pays at 18% of total charges,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.25,50,,,percent of total billed charges,pays at 50% of total billed charges,50.75,70,,,percent of total billed charges,70% of total billed charges,54.38,75,,,percent of total billed charges,75% of total billed charges,36.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,72.5,
DRILL TIP ULTRA DRIVE,3610299,CDM,272,RC,,,Outpatient,,,1216,729.6,,218.88,18,,,percent of total billed charges,pays at 18% of total charges,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,608,50,,,percent of total billed charges,pays at 50% of total billed charges,851.2,70,,,percent of total billed charges,70% of total billed charges,912,75,,,percent of total billed charges,75% of total billed charges,608,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,729.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,547.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,729.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,851.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,583.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1216,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1094.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.55,1216,
SUTURE DEXON,3610300,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
SUTURE ETHIBOND CR,3610312,CDM,272,RC,,,Outpatient,,,27.5,16.5,,4.95,18,,,percent of total billed charges,pays at 18% of total charges,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.75,50,,,percent of total billed charges,pays at 50% of total billed charges,19.25,70,,,percent of total billed charges,70% of total billed charges,20.63,75,,,percent of total billed charges,75% of total billed charges,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,27.5,
SUTURE ETHIBOND 2-0,3610318,CDM,272,RC,,,Outpatient,,,28.5,17.1,,5.13,18,,,percent of total billed charges,pays at 18% of total charges,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.25,50,,,percent of total billed charges,pays at 50% of total billed charges,19.95,70,,,percent of total billed charges,70% of total billed charges,21.38,75,,,percent of total billed charges,75% of total billed charges,14.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,28.5,
SUTURE ETHIBOND MULTI NDL,3610321,CDM,272,RC,,,Outpatient,,,111,66.6,,19.98,18,,,percent of total billed charges,pays at 18% of total charges,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.5,50,,,percent of total billed charges,pays at 50% of total billed charges,77.7,70,,,percent of total billed charges,70% of total billed charges,83.25,75,,,percent of total billed charges,75% of total billed charges,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,111,
SUTURE ETHIBOND XTRA,3610326,CDM,272,RC,,,Outpatient,,,35.5,21.3,,6.39,18,,,percent of total billed charges,pays at 18% of total charges,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.75,50,,,percent of total billed charges,pays at 50% of total billed charges,24.85,70,,,percent of total billed charges,70% of total billed charges,26.63,75,,,percent of total billed charges,75% of total billed charges,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.56,35.5,
SUTURE ETHILON 1-0,3610344,CDM,272,RC,,,Outpatient,,,19,11.4,,3.42,18,,,percent of total billed charges,pays at 18% of total charges,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,19,
SUTURE ETHILON 2-0,3610346,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
SUTURE ETHILON 3-0,3610350,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
SUTURE PROLENE 10-0,3610351,CDM,272,RC,,,Outpatient,,,85,51,,15.3,18,,,percent of total billed charges,pays at 18% of total charges,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.5,50,,,percent of total billed charges,pays at 50% of total billed charges,59.5,70,,,percent of total billed charges,70% of total billed charges,63.75,75,,,percent of total billed charges,75% of total billed charges,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,85,
SUTURE ETHILON 4-0,3610356,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
SUTURE ETHILON 5-0,3610362,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
SUTURE ETHILON 8-0,3610368,CDM,272,RC,,,Outpatient,,,33.5,20.1,,6.03,18,,,percent of total billed charges,pays at 18% of total charges,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.75,50,,,percent of total billed charges,pays at 50% of total billed charges,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,16.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,33.5,
SUTURE ETHILON 6-0,3610370,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SUTURE ETHILON 10-0,3610378,CDM,272,RC,,,Outpatient,,,171,102.6,,30.78,18,,,percent of total billed charges,pays at 18% of total charges,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,50,,,percent of total billed charges,pays at 50% of total billed charges,119.7,70,,,percent of total billed charges,70% of total billed charges,128.25,75,,,percent of total billed charges,75% of total billed charges,85.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,171,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.8,171,
SUTURE MERSILINE,3610404,CDM,272,RC,,,Outpatient,,,147,88.2,,26.46,18,,,percent of total billed charges,pays at 18% of total charges,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.5,50,,,percent of total billed charges,pays at 50% of total billed charges,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,73.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,147,
SUTURE NUROLON,3610412,CDM,272,RC,,,Outpatient,,,56.5,33.9,,10.17,18,,,percent of total billed charges,pays at 18% of total charges,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.25,50,,,percent of total billed charges,pays at 50% of total billed charges,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,56.5,
SUTURE PDS,3610418,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SUTURE ETHILON 9-0,3610439,CDM,272,RC,,,Outpatient,,,62,37.2,,11.16,18,,,percent of total billed charges,pays at 18% of total charges,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,62,
SUTURE PLAIN GUT 1-0,3610440,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SUTURE ETHIBOND XTRA 0,3610447,CDM,272,RC,,,Outpatient,,,23,13.8,,4.14,18,,,percent of total billed charges,pays at 18% of total charges,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.5,50,,,percent of total billed charges,pays at 50% of total billed charges,16.1,70,,,percent of total billed charges,70% of total billed charges,17.25,75,,,percent of total billed charges,75% of total billed charges,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,23,
SUTURE PLAIN GUT 2-0,3610448,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SUTURE PLAIN GUT 3-0,3610454,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE PLAIN GUT 4-0,3610456,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
CATH SWAN GANZ,3610471,CDM,272,RC,,,Outpatient,,,575,345,,103.5,18,,,percent of total billed charges,pays at 18% of total charges,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.5,50,,,percent of total billed charges,pays at 50% of total billed charges,402.5,70,,,percent of total billed charges,70% of total billed charges,431.25,75,,,percent of total billed charges,75% of total billed charges,287.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,439.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,402.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,345,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,517.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.1,575,
CUTTER METAL LEGEND DISP,3610473,CDM,272,RC,,,Outpatient,,,244.5,146.7,,44.01,18,,,percent of total billed charges,pays at 18% of total charges,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.25,50,,,percent of total billed charges,pays at 50% of total billed charges,171.15,70,,,percent of total billed charges,70% of total billed charges,183.38,75,,,percent of total billed charges,75% of total billed charges,122.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,171.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,244.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.31,244.5,
SUTURE PLAIN GUT 5-0,3610482,CDM,272,RC,,,Outpatient,,,26.5,15.9,,4.77,18,,,percent of total billed charges,pays at 18% of total charges,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.25,50,,,percent of total billed charges,pays at 50% of total billed charges,18.55,70,,,percent of total billed charges,70% of total billed charges,19.88,75,,,percent of total billed charges,75% of total billed charges,13.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,26.5,
PACK NEEDLE DELIVERY,3610483,CDM,272,RC,,,Outpatient,,,570,342,,102.6,18,,,percent of total billed charges,pays at 18% of total charges,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285,50,,,percent of total billed charges,pays at 50% of total billed charges,399,70,,,percent of total billed charges,70% of total billed charges,427.5,75,,,percent of total billed charges,75% of total billed charges,285,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,436.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,399,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,570,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,513,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.32,570,
SUTURE PLAIN GUT 6-0,3610488,CDM,272,RC,,,Outpatient,,,64,38.4,,11.52,18,,,percent of total billed charges,pays at 18% of total charges,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32,50,,,percent of total billed charges,pays at 50% of total billed charges,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,64,
PATELLA POLY,3610513,CDM,278,RC,C1776,HCPCS,Outpatient,,,5460,3276,,982.8,18,,,percent of total billed charges,pays at 18% of total charges,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,982.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3822,70,,,percent of total billed charges,70% of total billed charges,4095,75,,,percent of total billed charges,75% of total billed charges,2730,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3276,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5460,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,940.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2457,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3822,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3276,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3822,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2620.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5460,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5460,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.58,5460,
SUTURE PROLENE 1-0,3610518,CDM,272,RC,,,Outpatient,,,23,13.8,,4.14,18,,,percent of total billed charges,pays at 18% of total charges,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.5,50,,,percent of total billed charges,pays at 50% of total billed charges,16.1,70,,,percent of total billed charges,70% of total billed charges,17.25,75,,,percent of total billed charges,75% of total billed charges,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,23,
SUTURE PROLENE 2-0,3610526,CDM,272,RC,,,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21,50,,,percent of total billed charges,pays at 50% of total billed charges,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
SUTURE PROLENE 3-0,3610538,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SUTURE PROLENE 4-0,3610546,CDM,272,RC,,,Outpatient,,,55.5,33.3,,9.99,18,,,percent of total billed charges,pays at 18% of total charges,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.75,50,,,percent of total billed charges,pays at 50% of total billed charges,38.85,70,,,percent of total billed charges,70% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,27.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,55.5,
SUTURE ETHIBOND XTRA 1-0,3610551,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
SUTURE PROLENE 5-0,3610556,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SUTURE PROLENE 5-0,3610557,CDM,272,RC,,,Outpatient,,,82,49.2,,14.76,18,,,percent of total billed charges,pays at 18% of total charges,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41,50,,,percent of total billed charges,pays at 50% of total billed charges,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,82,
PATCH FIBRIN SEALANT,3610561,CDM,272,RC,,,Outpatient,,,1150.5,690.3,,207.09,18,,,percent of total billed charges,pays at 18% of total charges,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,575.25,50,,,percent of total billed charges,pays at 50% of total billed charges,805.35,70,,,percent of total billed charges,70% of total billed charges,862.88,75,,,percent of total billed charges,75% of total billed charges,575.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,920.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,690.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,880.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,805.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,690.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1150.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1035.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.28,1150.5,
SUTURE PROLENE 6-0,3610594,CDM,272,RC,,,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
SUTURE PROLENE 7-0,3610595,CDM,272,RC,,,Outpatient,,,162,97.2,,29.16,18,,,percent of total billed charges,pays at 18% of total charges,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,50,,,percent of total billed charges,pays at 50% of total billed charges,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,162,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,162,
SUTURE PROLENE 7-0,3610596,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
SUTURE PROLENE MULTI NDL,3610598,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
SUTURE PROLENE 8,3610600,CDM,272,RC,,,Outpatient,,,158.5,95.1,,28.53,18,,,percent of total billed charges,pays at 18% of total charges,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.25,50,,,percent of total billed charges,pays at 50% of total billed charges,110.95,70,,,percent of total billed charges,70% of total billed charges,118.88,75,,,percent of total billed charges,75% of total billed charges,79.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,158.5,
SUTURE BOLSTER,3610610,CDM,272,RC,,,Outpatient,,,26.5,15.9,,4.77,18,,,percent of total billed charges,pays at 18% of total charges,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.25,50,,,percent of total billed charges,pays at 50% of total billed charges,18.55,70,,,percent of total billed charges,70% of total billed charges,19.88,75,,,percent of total billed charges,75% of total billed charges,13.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,26.5,
SUTURE RETEN BRIDGE,3610612,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
COVER BUR HOLE,3610615,CDM,278,RC,,,Outpatient,,,340,204,,61.2,18,,,percent of total billed charges,pays at 18% of total charges,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170,50,,,percent of total billed charges,pays at 50% of total billed charges,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
SUTURE SILK 1 0,3610620,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SUTURE SILK 0,3610622,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
PIN STEINMAN,3610631,CDM,278,RC,C1713,HCPCS,Outpatient,,,161.5,96.9,,29.07,18,,,percent of total billed charges,pays at 18% of total charges,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.05,70,,,percent of total billed charges,70% of total billed charges,121.13,75,,,percent of total billed charges,75% of total billed charges,80.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,161.5,
MESH VISILEX,3610643,CDM,278,RC,C1781,HCPCS,Outpatient,,,329,197.4,,59.22,18,,,percent of total billed charges,pays at 18% of total charges,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.3,70,,,percent of total billed charges,70% of total billed charges,246.75,75,,,percent of total billed charges,75% of total billed charges,164.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,329,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,230.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,329,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,329,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.55,329,
SUTURE SILK 2-0,3610646,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SCREW CANC 6.5,3610651,CDM,278,RC,C1713,HCPCS,Outpatient,,,421.5,252.9,,75.87,18,,,percent of total billed charges,pays at 18% of total charges,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.05,70,,,percent of total billed charges,70% of total billed charges,316.13,75,,,percent of total billed charges,75% of total billed charges,210.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,295.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,252.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,295.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,421.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,421.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,421.5,
DRAIN ROUND,3610655,CDM,272,RC,C1729,HCPCS,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
SUTURE SILK CR,3610660,CDM,272,RC,,,Outpatient,,,81,48.6,,14.58,18,,,percent of total billed charges,pays at 18% of total charges,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,81,
DRAIN BECKER EDMS,3610667,CDM,272,RC,C1729,HCPCS,Outpatient,,,418,250.8,,75.24,18,,,percent of total billed charges,pays at 18% of total charges,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,209,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,376.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,418,
SUTURE SILK 3-0,3610672,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
WIRE OLIVE,3610679,CDM,272,RC,,,Outpatient,,,298,178.8,,53.64,18,,,percent of total billed charges,pays at 18% of total charges,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149,50,,,percent of total billed charges,pays at 50% of total billed charges,208.6,70,,,percent of total billed charges,70% of total billed charges,223.5,75,,,percent of total billed charges,75% of total billed charges,149,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,208.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,298,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,268.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.7,298,
PLATE 1/3 TUBULAR 6H - 10H,3610695,CDM,278,RC,C1713,HCPCS,Outpatient,,,109,65.4,,19.62,18,,,percent of total billed charges,pays at 18% of total charges,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,54.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,109,
SUTURE SILK 4-0,3610696,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SUTURE SILK 5-0,3610714,CDM,272,RC,,,Outpatient,,,23,13.8,,4.14,18,,,percent of total billed charges,pays at 18% of total charges,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.5,50,,,percent of total billed charges,pays at 50% of total billed charges,16.1,70,,,percent of total billed charges,70% of total billed charges,17.25,75,,,percent of total billed charges,75% of total billed charges,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,23,
SUTURE SILK 6-0,3610721,CDM,272,RC,,,Outpatient,,,32.5,19.5,,5.85,18,,,percent of total billed charges,pays at 18% of total charges,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.25,50,,,percent of total billed charges,pays at 50% of total billed charges,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,16.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,32.5,
SUTURE SILK 7-0,3610728,CDM,272,RC,,,Outpatient,,,77.5,46.5,,13.95,18,,,percent of total billed charges,pays at 18% of total charges,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.75,50,,,percent of total billed charges,pays at 50% of total billed charges,54.25,70,,,percent of total billed charges,70% of total billed charges,58.13,75,,,percent of total billed charges,75% of total billed charges,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,77.5,
STAPLE COMPRESSION,3610737,CDM,278,RC,C1776,HCPCS,Outpatient,,,900,540,,162,18,,,percent of total billed charges,pays at 18% of total charges,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,70,,,percent of total billed charges,70% of total billed charges,675,75,,,percent of total billed charges,75% of total billed charges,450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.03,900,
SUTURE STEEL,3610744,CDM,272,RC,,,Outpatient,,,67,40.2,,12.06,18,,,percent of total billed charges,pays at 18% of total charges,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,50,,,percent of total billed charges,pays at 50% of total billed charges,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,67,
SUTURE TICRON CTD,3610770,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE VICRYL 0,3610778,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE VICRYL 2-0,3610780,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE VICRYL 1-0,3610796,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
SUTURE VICRYL SUTUPAK,3610803,CDM,272,RC,,,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
SUTURE D SPECIAL,3610820,CDM,272,RC,,,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
SUTURE VICRYL 5-0,3610840,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE VICRYL 4-0,3610846,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE VICRYL 6-0,3610862,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
SUTURE VICRYL MULTI NDL,3610878,CDM,272,RC,,,Outpatient,,,105,63,,18.9,18,,,percent of total billed charges,pays at 18% of total charges,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,50,,,percent of total billed charges,pays at 50% of total billed charges,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,105,
SUTURE VICRYL 8-0,3610885,CDM,272,RC,,,Outpatient,,,105,63,,18.9,18,,,percent of total billed charges,pays at 18% of total charges,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,50,,,percent of total billed charges,pays at 50% of total billed charges,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,105,
SUTURE UMBILICAL U15,3610892,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
POUCH ANTIMICROBIAL,3610901,CDM,278,RC,,,Outpatient,,,1203,721.8,,216.54,18,,,percent of total billed charges,pays at 18% of total charges,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,601.5,50,,,percent of total billed charges,pays at 50% of total billed charges,842.1,70,,,percent of total billed charges,70% of total billed charges,902.25,75,,,percent of total billed charges,75% of total billed charges,601.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,962.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,721.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1203,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,842.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,842.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1203,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1203,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.51,1203,
DSG  ANTIMICROBIAL,3610905,CDM,272,RC,,,Outpatient,,,97,58.2,,17.46,18,,,percent of total billed charges,pays at 18% of total charges,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.5,50,,,percent of total billed charges,pays at 50% of total billed charges,67.9,70,,,percent of total billed charges,70% of total billed charges,72.75,75,,,percent of total billed charges,75% of total billed charges,48.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.2,97,
PLATE WRIST,3610906,CDM,278,RC,C1713,HCPCS,Outpatient,,,4527,2716.2,,814.86,18,,,percent of total billed charges,pays at 18% of total charges,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3168.9,70,,,percent of total billed charges,70% of total billed charges,3395.25,75,,,percent of total billed charges,75% of total billed charges,2263.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3621.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2716.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4527,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,780,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2037.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3168.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2716.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1720.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3168.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2172.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4527,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4527,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.38,4527,
KIT COMBO MIS SUTURE FAST DEVICE,3610910,CDM,272,RC,,,Outpatient,,,988,592.8,,177.84,18,,,percent of total billed charges,pays at 18% of total charges,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,494,50,,,percent of total billed charges,pays at 50% of total billed charges,691.6,70,,,percent of total billed charges,70% of total billed charges,741,75,,,percent of total billed charges,75% of total billed charges,494,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,691.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,691.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,988,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,889.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.82,988,
KIT COMBO MINI SUTURE FAST DEVICE,3610912,CDM,272,RC,,,Outpatient,,,166.25,99.75,,29.93,18,,,percent of total billed charges,pays at 18% of total charges,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.13,50,,,percent of total billed charges,pays at 50% of total billed charges,116.38,70,,,percent of total billed charges,70% of total billed charges,124.69,75,,,percent of total billed charges,75% of total billed charges,83.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,116.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,166.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,149.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.05,166.25,
SUTURE FASTENER SINGLE,3610913,CDM,272,RC,,,Outpatient,,,864.5,518.7,,155.61,18,,,percent of total billed charges,pays at 18% of total charges,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,432.25,50,,,percent of total billed charges,pays at 50% of total billed charges,605.15,70,,,percent of total billed charges,70% of total billed charges,648.38,75,,,percent of total billed charges,75% of total billed charges,432.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,691.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,518.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,661.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,605.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,518.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,605.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,864.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,778.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.47,864.5,
SUTURE FASTENER MULTI POUCH,3610914,CDM,272,RC,,,Outpatient,,,360,216,,64.8,18,,,percent of total billed charges,pays at 18% of total charges,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,50,,,percent of total billed charges,pays at 50% of total billed charges,252,70,,,percent of total billed charges,70% of total billed charges,270,75,,,percent of total billed charges,75% of total billed charges,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,360,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,360,
NDL ELECTRODE TWISTED PR,3610921,CDM,272,RC,,,Outpatient,,,737,442.2,,132.66,18,,,percent of total billed charges,pays at 18% of total charges,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.5,50,,,percent of total billed charges,pays at 50% of total billed charges,515.9,70,,,percent of total billed charges,70% of total billed charges,552.75,75,,,percent of total billed charges,75% of total billed charges,368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,589.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,563.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,515.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,515.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,737,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,663.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.49,737,
PROBE BALL TIP DISP,3610922,CDM,272,RC,,,Outpatient,,,242.5,145.5,,43.65,18,,,percent of total billed charges,pays at 18% of total charges,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.25,50,,,percent of total billed charges,pays at 50% of total billed charges,169.75,70,,,percent of total billed charges,70% of total billed charges,181.88,75,,,percent of total billed charges,75% of total billed charges,121.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,169.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,242.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,218.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38,242.5,
PROBE BALL TIP,3610924,CDM,272,RC,,,Outpatient,,,465.4,279.24,,83.77,18,,,percent of total billed charges,pays at 18% of total charges,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.7,50,,,percent of total billed charges,pays at 50% of total billed charges,325.78,70,,,percent of total billed charges,70% of total billed charges,349.05,75,,,percent of total billed charges,75% of total billed charges,232.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,356.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,325.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,325.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,465.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,418.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.93,465.4,
NEEDLE NIM SPINE PEDICLE,3610926,CDM,272,RC,,,Outpatient,,,975,585,,175.5,18,,,percent of total billed charges,pays at 18% of total charges,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.5,50,,,percent of total billed charges,pays at 50% of total billed charges,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,745.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,877.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
IMPLANT BICEPS,3610930,CDM,278,RC,C1776,HCPCS,Outpatient,,,744,446.4,,133.92,18,,,percent of total billed charges,pays at 18% of total charges,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.8,70,,,percent of total billed charges,70% of total billed charges,558,75,,,percent of total billed charges,75% of total billed charges,372,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,595.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,446.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.58,744,
IMPLANT BUNION,3610931,CDM,278,RC,C1776,HCPCS,Outpatient,,,3323,1993.8,,598.14,18,,,percent of total billed charges,pays at 18% of total charges,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2326.1,70,,,percent of total billed charges,70% of total billed charges,2492.25,75,,,percent of total billed charges,75% of total billed charges,1661.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2658.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1993.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3323,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,572.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1495.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2326.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1993.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1262.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2326.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3323,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3323,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.71,3323,
KIT PERM BIRTH CTRL,3610932,CDM,278,RC,,,Outpatient,,,2015,1209,,362.7,18,,,percent of total billed charges,pays at 18% of total charges,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1007.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1410.5,70,,,percent of total billed charges,70% of total billed charges,1511.25,75,,,percent of total billed charges,75% of total billed charges,1007.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1209,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2015,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,906.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1410.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1209,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1410.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2015,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2015,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.75,2015,
KIT DISP BUNION INSTRUMENT,3610933,CDM,272,RC,,,Outpatient,,,1659,995.4,,298.62,18,,,percent of total billed charges,pays at 18% of total charges,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,829.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1161.3,70,,,percent of total billed charges,70% of total billed charges,1244.25,75,,,percent of total billed charges,75% of total billed charges,829.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1327.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,995.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1269.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1161.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,995.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1161.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1659,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1493.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.97,1659,
KIT DISP BUNION DRILL,3610934,CDM,272,RC,,,Outpatient,,,1035,621,,186.3,18,,,percent of total billed charges,pays at 18% of total charges,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,517.5,50,,,percent of total billed charges,pays at 50% of total billed charges,724.5,70,,,percent of total billed charges,70% of total billed charges,776.25,75,,,percent of total billed charges,75% of total billed charges,517.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,828,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,621,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,791.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,724.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,621,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,724.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1035,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,931.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.18,1035,
ROD CLOSED OFFSET,3610935,CDM,278,RC,C1713,HCPCS,Outpatient,,,1700.4,1020.24,,306.07,18,,,percent of total billed charges,pays at 18% of total charges,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.28,70,,,percent of total billed charges,70% of total billed charges,1275.3,75,,,percent of total billed charges,75% of total billed charges,850.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1360.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1020.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1700.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,292.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1190.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1020.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,646.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1190.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,816.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1700.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1700.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.45,1700.4,
HUMERAL CUP,3610936,CDM,278,RC,C1776,HCPCS,Outpatient,,,2795,1677,,503.1,18,,,percent of total billed charges,pays at 18% of total charges,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1956.5,70,,,percent of total billed charges,70% of total billed charges,2096.25,75,,,percent of total billed charges,75% of total billed charges,1397.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1677,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2795,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,481.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1956.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1677,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1062.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1956.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1341.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2795,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2795,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.98,2795,
HUMERAL INLAY REVERSE,3610937,CDM,278,RC,C1776,HCPCS,Outpatient,,,2340,1404,,421.2,18,,,percent of total billed charges,pays at 18% of total charges,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,421.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638,70,,,percent of total billed charges,70% of total billed charges,1755,75,,,percent of total billed charges,75% of total billed charges,1170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1404,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,403.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1638,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1404,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,889.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1638,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1123.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.68,2340,
SLING ULTRA,3611000,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
PACK VNUS CLOSURE,3611011,CDM,272,RC,,,Outpatient,,,134.5,80.7,,24.21,18,,,percent of total billed charges,pays at 18% of total charges,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.25,50,,,percent of total billed charges,pays at 50% of total billed charges,94.15,70,,,percent of total billed charges,70% of total billed charges,100.88,75,,,percent of total billed charges,75% of total billed charges,67.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,134.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.08,134.5,
SET SHEATH INTRODUCER,3611012,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
CATH VNUS CLOSURE,3611013,CDM,272,RC,,,Outpatient,,,1038.5,623.1,,186.93,18,,,percent of total billed charges,pays at 18% of total charges,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,519.25,50,,,percent of total billed charges,pays at 50% of total billed charges,726.95,70,,,percent of total billed charges,70% of total billed charges,778.88,75,,,percent of total billed charges,75% of total billed charges,519.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,830.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,623.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,794.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,726.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,623.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,726.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1038.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,934.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.73,1038.5,
GUIDEWIRE VNUS,3611014,CDM,272,RC,C1769,HCPCS,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
PUNCH BIOCORKSCREW,3611015,CDM,272,RC,,,Outpatient,,,157.5,94.5,,28.35,18,,,percent of total billed charges,pays at 18% of total charges,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.75,50,,,percent of total billed charges,pays at 50% of total billed charges,110.25,70,,,percent of total billed charges,70% of total billed charges,118.13,75,,,percent of total billed charges,75% of total billed charges,78.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,157.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,141.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,157.5,
FIBERCHAIN,3611016,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
ALLOGRAFT CORNERSTONE,3611017,CDM,278,RC,C1762,HCPCS,Outpatient,,,1375.5,825.3,,247.59,18,,,percent of total billed charges,pays at 18% of total charges,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.85,70,,,percent of total billed charges,70% of total billed charges,1031.63,75,,,percent of total billed charges,75% of total billed charges,687.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1375.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,237,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,962.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,825.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,522.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,962.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1375.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1375.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.54,1375.5,
SUTURE DACRON,3611020,CDM,272,RC,,,Outpatient,,,77.5,46.5,,13.95,18,,,percent of total billed charges,pays at 18% of total charges,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.75,50,,,percent of total billed charges,pays at 50% of total billed charges,54.25,70,,,percent of total billed charges,70% of total billed charges,58.13,75,,,percent of total billed charges,75% of total billed charges,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,77.5,
WALKER FOOTWEAR INLINE,3611023,CDM,272,RC,,,Outpatient,,,81,48.6,,14.58,18,,,percent of total billed charges,pays at 18% of total charges,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,81,
ALLOGRAFT DBM FLEX,3611024,CDM,278,RC,C9359,HCPCS,Outpatient,,,1470.3,882.18,,264.65,18,,,percent of total billed charges,pays at 18% of total charges,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,735.15,50,,,percent of total billed charges,pays at 50% of total billed charges,1029.21,70,,,percent of total billed charges,70% of total billed charges,1102.73,75,,,percent of total billed charges,75% of total billed charges,735.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1176.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,882.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1470.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,253.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1029.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,882.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,558.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1029.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1470.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1470.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.4,1470.3,
SLING ULTRA,3611030,CDM,272,RC,,,Outpatient,,,206,123.6,,37.08,18,,,percent of total billed charges,pays at 18% of total charges,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103,50,,,percent of total billed charges,pays at 50% of total billed charges,144.2,70,,,percent of total billed charges,70% of total billed charges,154.5,75,,,percent of total billed charges,75% of total billed charges,103,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,206,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,185.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,206,
CANNULA RCSP,3611034,CDM,272,RC,,,Outpatient,,,232,139.2,,41.76,18,,,percent of total billed charges,pays at 18% of total charges,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116,50,,,percent of total billed charges,pays at 50% of total billed charges,162.4,70,,,percent of total billed charges,70% of total billed charges,174,75,,,percent of total billed charges,75% of total billed charges,116,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,232,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,208.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,232,
PROSTHESIS TESTICULAR,3611037,CDM,278,RC,,,Outpatient,,,2946,1767.6,,530.28,18,,,percent of total billed charges,pays at 18% of total charges,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1473,50,,,percent of total billed charges,pays at 50% of total billed charges,2062.2,70,,,percent of total billed charges,70% of total billed charges,2209.5,75,,,percent of total billed charges,75% of total billed charges,1473,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1767.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2946,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1325.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2062.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1767.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1119.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2062.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1414.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2946,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2946,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.64,2946,
PENILE PROSTHESIS MALLEABLE,3611038,CDM,278,RC,C1813,HCPCS,Outpatient,,,12000,7200,,2160,18,,,percent of total billed charges,pays at 18% of total charges,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2160,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8400,70,,,percent of total billed charges,70% of total billed charges,9000,75,,,percent of total billed charges,75% of total billed charges,6000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12000,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2067.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4560,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5760,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1880.4,12000,
GUIDE DRILL RETRO,3611041,CDM,272,RC,,,Outpatient,,,305.5,183.3,,54.99,18,,,percent of total billed charges,pays at 18% of total charges,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.75,50,,,percent of total billed charges,pays at 50% of total billed charges,213.85,70,,,percent of total billed charges,70% of total billed charges,229.13,75,,,percent of total billed charges,75% of total billed charges,152.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,233.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,213.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,213.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,305.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,274.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.87,305.5,
SUTURE BUTTON ANKLE ZIPTIGHT,3611042,CDM,278,RC,C1713,HCPCS,Outpatient,,,1095.9,657.54,,197.26,18,,,percent of total billed charges,pays at 18% of total charges,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.13,70,,,percent of total billed charges,70% of total billed charges,821.93,75,,,percent of total billed charges,75% of total billed charges,547.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,876.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1095.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,188.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,767.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,657.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,767.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1095.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1095.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.73,1095.9,
RETRO CUTTER,3611043,CDM,272,RC,,,Outpatient,,,605,363,,108.9,18,,,percent of total billed charges,pays at 18% of total charges,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.5,50,,,percent of total billed charges,pays at 50% of total billed charges,423.5,70,,,percent of total billed charges,70% of total billed charges,453.75,75,,,percent of total billed charges,75% of total billed charges,302.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,423.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,605,
SUTURE BUTTON ANKLE ZIPTIGHT,3611044,CDM,278,RC,C1713,HCPCS,Outpatient,,,1284.4,770.64,,231.19,18,,,percent of total billed charges,pays at 18% of total charges,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.08,70,,,percent of total billed charges,70% of total billed charges,963.3,75,,,percent of total billed charges,75% of total billed charges,642.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1027.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,770.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1284.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,221.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,899.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,770.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,488.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,899.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1284.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1284.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.27,1284.4,
STAPLE LIGAMENT SPIKE,3611045,CDM,278,RC,C1713,HCPCS,Outpatient,,,243.5,146.1,,43.83,18,,,percent of total billed charges,pays at 18% of total charges,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.45,70,,,percent of total billed charges,70% of total billed charges,182.63,75,,,percent of total billed charges,75% of total billed charges,121.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,170.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,170.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,243.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.16,243.5,
SYS STAPLE NITINOL ANGLED,3611046,CDM,278,RC,C1713,HCPCS,Outpatient,,,2140.13,1284.08,,385.22,18,,,percent of total billed charges,pays at 18% of total charges,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.09,70,,,percent of total billed charges,70% of total billed charges,1605.1,75,,,percent of total billed charges,75% of total billed charges,1070.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1712.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1284.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2140.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,368.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1498.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1284.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,813.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1498.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2140.13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2140.13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.36,2140.13,
SUTURE BUTTON,3611047,CDM,278,RC,C1713,HCPCS,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
DURA PRECLUDE 10X12,3611051,CDM,278,RC,C1763,HCPCS,Outpatient,,,1973,1183.8,,355.14,18,,,percent of total billed charges,pays at 18% of total charges,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.1,70,,,percent of total billed charges,70% of total billed charges,1479.75,75,,,percent of total billed charges,75% of total billed charges,986.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1183.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1973,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,339.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1381.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1183.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1381.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,947.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1973,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1973,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.17,1973,
CATH REDDICK CHOLANGIOGRAM,3611055,CDM,272,RC,,,Outpatient,,,179.5,107.7,,32.31,18,,,percent of total billed charges,pays at 18% of total charges,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.75,50,,,percent of total billed charges,pays at 50% of total billed charges,125.65,70,,,percent of total billed charges,70% of total billed charges,134.63,75,,,percent of total billed charges,75% of total billed charges,89.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,125.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,179.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,161.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,179.5,
CABLE CONNECTOR SNAP LID,3611059,CDM,272,RC,,,Outpatient,,,518.5,311.1,,93.33,18,,,percent of total billed charges,pays at 18% of total charges,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.25,50,,,percent of total billed charges,pays at 50% of total billed charges,362.95,70,,,percent of total billed charges,70% of total billed charges,388.88,75,,,percent of total billed charges,75% of total billed charges,259.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,414.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,518.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,466.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.25,518.5,
ARM STRAP,3611064,CDM,272,RC,,,Outpatient,,,154,92.4,,27.72,18,,,percent of total billed charges,pays at 18% of total charges,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77,50,,,percent of total billed charges,pays at 50% of total billed charges,107.8,70,,,percent of total billed charges,70% of total billed charges,115.5,75,,,percent of total billed charges,75% of total billed charges,77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,154,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,138.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.13,154,
PACK MINOR EXTREMITY,3611075,CDM,272,RC,,,Outpatient,,,77.82,46.69,,14.01,18,,,percent of total billed charges,pays at 18% of total charges,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.91,50,,,percent of total billed charges,pays at 50% of total billed charges,54.47,70,,,percent of total billed charges,70% of total billed charges,58.37,75,,,percent of total billed charges,75% of total billed charges,38.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,77.82,
PACK ARTHROSCOPY,3611076,CDM,272,RC,,,Outpatient,,,187,112.2,,33.66,18,,,percent of total billed charges,pays at 18% of total charges,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.5,50,,,percent of total billed charges,pays at 50% of total billed charges,130.9,70,,,percent of total billed charges,70% of total billed charges,140.25,75,,,percent of total billed charges,75% of total billed charges,93.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,187,
PACK SHOULDER ARTHROSCOPY,3611079,CDM,272,RC,,,Outpatient,,,138.4,83.04,,24.91,18,,,percent of total billed charges,pays at 18% of total charges,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.2,50,,,percent of total billed charges,pays at 50% of total billed charges,96.88,70,,,percent of total billed charges,70% of total billed charges,103.8,75,,,percent of total billed charges,75% of total billed charges,69.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,138.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,124.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.69,138.4,
PACK HAND,3611081,CDM,272,RC,,,Outpatient,,,93.88,56.33,,16.9,18,,,percent of total billed charges,pays at 18% of total charges,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.94,50,,,percent of total billed charges,pays at 50% of total billed charges,65.72,70,,,percent of total billed charges,70% of total billed charges,70.41,75,,,percent of total billed charges,75% of total billed charges,46.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,65.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93.88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,84.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.71,93.88,
PACK MINOR SURG,3611082,CDM,272,RC,,,Outpatient,,,197.5,118.5,,35.55,18,,,percent of total billed charges,pays at 18% of total charges,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,98.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,197.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,197.5,
PACK CYSTO,3611083,CDM,272,RC,,,Outpatient,,,106,63.6,,19.08,18,,,percent of total billed charges,pays at 18% of total charges,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53,50,,,percent of total billed charges,pays at 50% of total billed charges,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,106,
HEART SUCT CONTROL VALVE,3611084,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
PROBE MYOCARDIAL TEMP,3611085,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
PACK ENT,3611086,CDM,272,RC,,,Outpatient,,,119.5,71.7,,21.51,18,,,percent of total billed charges,pays at 18% of total charges,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.75,50,,,percent of total billed charges,pays at 50% of total billed charges,83.65,70,,,percent of total billed charges,70% of total billed charges,89.63,75,,,percent of total billed charges,75% of total billed charges,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,83.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,119.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,119.5,
PACK CIRCUMCISION,3611087,CDM,272,RC,,,Outpatient,,,67,40.2,,12.06,18,,,percent of total billed charges,pays at 18% of total charges,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,50,,,percent of total billed charges,pays at 50% of total billed charges,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,67,
PACK EXTREMITY,3611088,CDM,272,RC,,,Outpatient,,,513.5,308.1,,92.43,18,,,percent of total billed charges,pays at 18% of total charges,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.75,50,,,percent of total billed charges,pays at 50% of total billed charges,359.45,70,,,percent of total billed charges,70% of total billed charges,385.13,75,,,percent of total billed charges,75% of total billed charges,256.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,410.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,359.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,359.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,513.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,462.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.47,513.5,
PACK MAJOR GENERAL,3611092,CDM,272,RC,,,Outpatient,,,200.5,120.3,,36.09,18,,,percent of total billed charges,pays at 18% of total charges,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.25,50,,,percent of total billed charges,pays at 50% of total billed charges,140.35,70,,,percent of total billed charges,70% of total billed charges,150.38,75,,,percent of total billed charges,75% of total billed charges,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,200.5,
PLATE 2 HOLE,3611093,CDM,278,RC,C1713,HCPCS,Outpatient,,,2229,1337.4,,401.22,18,,,percent of total billed charges,pays at 18% of total charges,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560.3,70,,,percent of total billed charges,70% of total billed charges,1671.75,75,,,percent of total billed charges,75% of total billed charges,1114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1783.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1337.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2229,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,384.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1560.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1337.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,847.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1560.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1069.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.28,2229,
PACK D&C HYSTEROSCOPY,3611095,CDM,272,RC,,,Outpatient,,,72,43.2,,12.96,18,,,percent of total billed charges,pays at 18% of total charges,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,50,,,percent of total billed charges,pays at 50% of total billed charges,50.4,70,,,percent of total billed charges,70% of total billed charges,54,75,,,percent of total billed charges,75% of total billed charges,36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.28,72,
ADAPTER PERFUSION,3611099,CDM,272,RC,,,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
TROCAR SPLIT DISP,3611105,CDM,272,RC,,,Outpatient,,,342,205.2,,61.56,18,,,percent of total billed charges,pays at 18% of total charges,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,50,,,percent of total billed charges,pays at 50% of total billed charges,239.4,70,,,percent of total billed charges,70% of total billed charges,256.5,75,,,percent of total billed charges,75% of total billed charges,171,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,239.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,239.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,342,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,307.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.59,342,
SCREW SLF DRLG,3611109,CDM,278,RC,C1713,HCPCS,Outpatient,,,466,279.6,,83.88,18,,,percent of total billed charges,pays at 18% of total charges,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.2,70,,,percent of total billed charges,70% of total billed charges,349.5,75,,,percent of total billed charges,75% of total billed charges,233,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,326.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,326.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,466,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,466,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,466,
BEARING HUMERAL,3611118,CDM,278,RC,C1776,HCPCS,Outpatient,,,1040,624,,187.2,18,,,percent of total billed charges,pays at 18% of total charges,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1040,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,179.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,1040,
ORTHO RING,3611119,CDM,272,RC,,,Outpatient,,,9674.6,5804.76,,1741.43,18,,,percent of total billed charges,pays at 18% of total charges,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1741.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4837.3,50,,,percent of total billed charges,pays at 50% of total billed charges,6772.22,70,,,percent of total billed charges,70% of total billed charges,7255.95,75,,,percent of total billed charges,75% of total billed charges,4837.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7739.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5804.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7401.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4353.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6772.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5804.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3676.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6772.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4643.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9674.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8707.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1516.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.01,9674.6,
WIRE OLIVE,3611121,CDM,278,RC,C1713,HCPCS,Outpatient,,,367.5,220.5,,66.15,18,,,percent of total billed charges,pays at 18% of total charges,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.25,70,,,percent of total billed charges,70% of total billed charges,275.63,75,,,percent of total billed charges,75% of total billed charges,183.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,294,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,257.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,257.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,367.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,367.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.59,367.5,
ELECTRODE BLADE TELFLON,3611122,CDM,272,RC,,,Outpatient,,,31.5,18.9,,5.67,18,,,percent of total billed charges,pays at 18% of total charges,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,50,,,percent of total billed charges,pays at 50% of total billed charges,22.05,70,,,percent of total billed charges,70% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,15.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,31.5,
WIRE SMOOTH,3611123,CDM,278,RC,C1713,HCPCS,Outpatient,,,277.5,166.5,,49.95,18,,,percent of total billed charges,pays at 18% of total charges,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.25,70,,,percent of total billed charges,70% of total billed charges,208.13,75,,,percent of total billed charges,75% of total billed charges,138.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,277.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.48,277.5,
BUSHING TIBIAL,3611124,CDM,278,RC,C1776,HCPCS,Outpatient,,,418.5,251.1,,75.33,18,,,percent of total billed charges,pays at 18% of total charges,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.95,70,,,percent of total billed charges,70% of total billed charges,313.88,75,,,percent of total billed charges,75% of total billed charges,209.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,418.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.58,418.5,
BUSHING ORTHO,3611125,CDM,272,RC,C1713,HCPCS,Outpatient,,,166.5,99.9,,29.97,18,,,percent of total billed charges,pays at 18% of total charges,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.55,70,,,percent of total billed charges,70% of total billed charges,124.88,75,,,percent of total billed charges,75% of total billed charges,83.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,116.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,166.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,149.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.09,166.5,
YOKE ORTHO,3611126,CDM,278,RC,C1776,HCPCS,Outpatient,,,1281.8,769.08,,230.72,18,,,percent of total billed charges,pays at 18% of total charges,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.26,70,,,percent of total billed charges,70% of total billed charges,961.35,75,,,percent of total billed charges,75% of total billed charges,640.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1025.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,769.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1281.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,897.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,769.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,897.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1281.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1281.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.86,1281.8,
WIRE POST ORTHO,3611127,CDM,272,RC,C1713,HCPCS,Outpatient,,,414.7,248.82,,74.65,18,,,percent of total billed charges,pays at 18% of total charges,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.29,70,,,percent of total billed charges,70% of total billed charges,311.03,75,,,percent of total billed charges,75% of total billed charges,207.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,290.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,414.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,373.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.98,414.7,
PIN CUBE ORTHO,3611128,CDM,272,RC,C1713,HCPCS,Outpatient,,,325.5,195.3,,58.59,18,,,percent of total billed charges,pays at 18% of total charges,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.85,70,,,percent of total billed charges,70% of total billed charges,244.13,75,,,percent of total billed charges,75% of total billed charges,162.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,227.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,227.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,325.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,292.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.01,325.5,
PIN HALF ORTHO,3611129,CDM,278,RC,C1713,HCPCS,Outpatient,,,268.5,161.1,,48.33,18,,,percent of total billed charges,pays at 18% of total charges,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.95,70,,,percent of total billed charges,70% of total billed charges,201.38,75,,,percent of total billed charges,75% of total billed charges,134.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,187.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,187.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,268.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.07,268.5,
BOLT ORTHO,3611130,CDM,272,RC,,,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,50,,,percent of total billed charges,pays at 50% of total billed charges,59.85,70,,,percent of total billed charges,70% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
CUTTER ETS FLEX,3611131,CDM,272,RC,,,Outpatient,,,431.5,258.9,,77.67,18,,,percent of total billed charges,pays at 18% of total charges,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,215.75,50,,,percent of total billed charges,pays at 50% of total billed charges,302.05,70,,,percent of total billed charges,70% of total billed charges,323.63,75,,,percent of total billed charges,75% of total billed charges,215.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,302.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,302.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,431.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,388.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.62,431.5,
GUIDEWIRE BALL TIP,3611133,CDM,272,RC,C1769,HCPCS,Outpatient,,,310,186,,55.8,18,,,percent of total billed charges,pays at 18% of total charges,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,310,
BOLT WIRE,3611134,CDM,272,RC,,,Outpatient,,,351,210.6,,63.18,18,,,percent of total billed charges,pays at 18% of total charges,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.5,50,,,percent of total billed charges,pays at 50% of total billed charges,245.7,70,,,percent of total billed charges,70% of total billed charges,263.25,75,,,percent of total billed charges,75% of total billed charges,175.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,351,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,315.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55,351,
NUT FLANGE,3611135,CDM,272,RC,,,Outpatient,,,169.5,101.7,,30.51,18,,,percent of total billed charges,pays at 18% of total charges,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.75,50,,,percent of total billed charges,pays at 50% of total billed charges,118.65,70,,,percent of total billed charges,70% of total billed charges,127.13,75,,,percent of total billed charges,75% of total billed charges,84.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.56,169.5,
NUT ORTHO,3611136,CDM,272,RC,,,Outpatient,,,54.25,32.55,,9.77,18,,,percent of total billed charges,pays at 18% of total charges,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.13,50,,,percent of total billed charges,pays at 50% of total billed charges,37.98,70,,,percent of total billed charges,70% of total billed charges,40.69,75,,,percent of total billed charges,75% of total billed charges,27.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,54.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.5,54.25,
CURETTE DISP,3611137,CDM,272,RC,,,Outpatient,,,40.2,24.12,,7.24,18,,,percent of total billed charges,pays at 18% of total charges,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.1,50,,,percent of total billed charges,pays at 50% of total billed charges,28.14,70,,,percent of total billed charges,70% of total billed charges,30.15,75,,,percent of total billed charges,75% of total billed charges,20.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,40.2,
SHUNT LUMBAR PERITONEAL,3611138,CDM,278,RC,,,Outpatient,,,728.73,437.24,,131.17,18,,,percent of total billed charges,pays at 18% of total charges,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364.37,50,,,percent of total billed charges,pays at 50% of total billed charges,510.11,70,,,percent of total billed charges,70% of total billed charges,546.55,75,,,percent of total billed charges,75% of total billed charges,364.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,582.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,728.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,510.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,437.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,510.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,728.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,728.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.19,728.73,
ACETABULAR CUP,3611139,CDM,278,RC,C1776,HCPCS,Outpatient,,,936,561.6,,168.48,18,,,percent of total billed charges,pays at 18% of total charges,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,70,,,percent of total billed charges,70% of total billed charges,702,75,,,percent of total billed charges,75% of total billed charges,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,561.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,161.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,655.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,561.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,355.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,655.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,936,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,936,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.67,936,
ACETABULAR LINER,3611140,CDM,278,RC,C1776,HCPCS,Outpatient,,,682.5,409.5,,122.85,18,,,percent of total billed charges,pays at 18% of total charges,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.75,70,,,percent of total billed charges,70% of total billed charges,511.88,75,,,percent of total billed charges,75% of total billed charges,341.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,546,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,409.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,682.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,409.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,682.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,682.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.95,682.5,
FEMORAL HEAD,3611141,CDM,278,RC,C1776,HCPCS,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
KNEE BUMPER INSERT,3611142,CDM,278,RC,C1713,HCPCS,Outpatient,,,2732,1639.2,,491.76,18,,,percent of total billed charges,pays at 18% of total charges,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,491.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1912.4,70,,,percent of total billed charges,70% of total billed charges,2049,75,,,percent of total billed charges,75% of total billed charges,1366,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1639.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2732,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,470.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1229.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1912.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1639.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1038.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1912.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2732,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2732,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.1,2732,
ROUTER TAPERED,3611143,CDM,272,RC,,,Outpatient,,,173,103.8,,31.14,18,,,percent of total billed charges,pays at 18% of total charges,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.5,50,,,percent of total billed charges,pays at 50% of total billed charges,121.1,70,,,percent of total billed charges,70% of total billed charges,129.75,75,,,percent of total billed charges,75% of total billed charges,86.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,121.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,173,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.11,173,
BONE FLAP,3611144,CDM,278,RC,,,Outpatient,,,15600,9360,,2808,18,,,percent of total billed charges,pays at 18% of total charges,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2808,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7800,50,,,percent of total billed charges,pays at 50% of total billed charges,10920,70,,,percent of total billed charges,70% of total billed charges,11700,75,,,percent of total billed charges,75% of total billed charges,7800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9360,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7020,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9360,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5928,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7488,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2444.52,15600,
SPIKE BONE,3611149,CDM,272,RC,,,Outpatient,,,80.55,48.33,,14.5,18,,,percent of total billed charges,pays at 18% of total charges,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.28,50,,,percent of total billed charges,pays at 50% of total billed charges,56.39,70,,,percent of total billed charges,70% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,40.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,80.55,
BOLT ORTHO,3611150,CDM,272,RC,,,Outpatient,,,429,257.4,,77.22,18,,,percent of total billed charges,pays at 18% of total charges,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.5,50,,,percent of total billed charges,pays at 50% of total billed charges,300.3,70,,,percent of total billed charges,70% of total billed charges,321.75,75,,,percent of total billed charges,75% of total billed charges,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,300.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,300.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,386.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.22,429,
FEMORAL CANAL BRUSH,3611324,CDM,272,RC,,,Outpatient,,,72.5,43.5,,13.05,18,,,percent of total billed charges,pays at 18% of total charges,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.25,50,,,percent of total billed charges,pays at 50% of total billed charges,50.75,70,,,percent of total billed charges,70% of total billed charges,54.38,75,,,percent of total billed charges,75% of total billed charges,36.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,72.5,
DRILL BIT 2.5,3611326,CDM,272,RC,,,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.5,50,,,percent of total billed charges,pays at 50% of total billed charges,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,333,
SCREW COMPRESSION,3611335,CDM,278,RC,C1713,HCPCS,Outpatient,,,447,268.2,,80.46,18,,,percent of total billed charges,pays at 18% of total charges,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.9,70,,,percent of total billed charges,70% of total billed charges,335.25,75,,,percent of total billed charges,75% of total billed charges,223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,357.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,312.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.04,447,
PUSHLOCK,3611344,CDM,272,RC,C1713,HCPCS,Outpatient,,,443.5,266.1,,79.83,18,,,percent of total billed charges,pays at 18% of total charges,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.45,70,,,percent of total billed charges,70% of total billed charges,332.63,75,,,percent of total billed charges,75% of total billed charges,221.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,339.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,310.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,310.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,443.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,399.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.5,443.5,
FIBER TAPE,3611346,CDM,272,RC,,,Outpatient,,,149.5,89.7,,26.91,18,,,percent of total billed charges,pays at 18% of total charges,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.75,50,,,percent of total billed charges,pays at 50% of total billed charges,104.65,70,,,percent of total billed charges,70% of total billed charges,112.13,75,,,percent of total billed charges,75% of total billed charges,74.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.43,149.5,
NAIL METACARPAL,3611347,CDM,278,RC,C1713,HCPCS,Outpatient,,,1205,723,,216.9,18,,,percent of total billed charges,pays at 18% of total charges,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.5,70,,,percent of total billed charges,70% of total billed charges,903.75,75,,,percent of total billed charges,75% of total billed charges,602.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,723,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,843.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,723,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,843.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.82,1205,
NAIL RADIUS DISTAL,3611348,CDM,278,RC,C1713,HCPCS,Outpatient,,,1205,723,,216.9,18,,,percent of total billed charges,pays at 18% of total charges,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.5,70,,,percent of total billed charges,70% of total billed charges,903.75,75,,,percent of total billed charges,75% of total billed charges,602.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,723,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,843.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,723,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,843.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.82,1205,
SPLINT NASAL,3611354,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
FEMORAL STEM,3611355,CDM,278,RC,C1776,HCPCS,Outpatient,,,8586,5151.6,,1545.48,18,,,percent of total billed charges,pays at 18% of total charges,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1545.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6010.2,70,,,percent of total billed charges,70% of total billed charges,6439.5,75,,,percent of total billed charges,75% of total billed charges,4293,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5151.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8586,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1479.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3863.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6010.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5151.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3262.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6010.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4121.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8586,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8586,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.43,8586,
REAMER STEP DISP,3611356,CDM,272,RC,,,Outpatient,,,1720.6,1032.36,,309.71,18,,,percent of total billed charges,pays at 18% of total charges,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,860.3,50,,,percent of total billed charges,pays at 50% of total billed charges,1204.42,70,,,percent of total billed charges,70% of total billed charges,1290.45,75,,,percent of total billed charges,75% of total billed charges,860.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1376.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1316.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1204.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1032.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,653.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1204.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1720.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1548.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.62,1720.6,
CLIP SUTURE,3611360,CDM,272,RC,,,Outpatient,,,107,64.2,,19.26,18,,,percent of total billed charges,pays at 18% of total charges,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.5,50,,,percent of total billed charges,pays at 50% of total billed charges,74.9,70,,,percent of total billed charges,70% of total billed charges,80.25,75,,,percent of total billed charges,75% of total billed charges,53.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,107,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,96.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.77,107,
RASP DISP,3611371,CDM,272,RC,,,Outpatient,,,650,390,,117,18,,,percent of total billed charges,pays at 18% of total charges,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325,50,,,percent of total billed charges,pays at 50% of total billed charges,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,325,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,497.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,585,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
GRAFT VASCULAR,3611551,CDM,278,RC,C1768,HCPCS,Outpatient,,,1552,931.2,,279.36,18,,,percent of total billed charges,pays at 18% of total charges,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1086.4,70,,,percent of total billed charges,70% of total billed charges,1164,75,,,percent of total billed charges,75% of total billed charges,776,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,931.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1552,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,267.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,698.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1086.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,931.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1086.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1552,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1552,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.2,1552,
INFLATOR LEVEEN 10CC,3611600,CDM,272,RC,,,Outpatient,,,91.5,54.9,,16.47,18,,,percent of total billed charges,pays at 18% of total charges,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.75,50,,,percent of total billed charges,pays at 50% of total billed charges,64.05,70,,,percent of total billed charges,70% of total billed charges,68.63,75,,,percent of total billed charges,75% of total billed charges,45.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,91.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,82.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,91.5,
LENS FOG RED DEV,3611704,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
LENS SCOPE SEAL,3611706,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
DEVICE TISSUE REMOVAL,3611709,CDM,272,RC,,,Outpatient,,,949,569.4,,170.82,18,,,percent of total billed charges,pays at 18% of total charges,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,474.5,50,,,percent of total billed charges,pays at 50% of total billed charges,664.3,70,,,percent of total billed charges,70% of total billed charges,711.75,75,,,percent of total billed charges,75% of total billed charges,474.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,759.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,569.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,725.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,664.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,569.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,664.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,949,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,854.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.71,949,
DEVICE TISSUE REMOVAL,3611710,CDM,272,RC,,,Outpatient,,,2042.3,1225.38,,367.61,18,,,percent of total billed charges,pays at 18% of total charges,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1021.15,50,,,percent of total billed charges,pays at 50% of total billed charges,1429.61,70,,,percent of total billed charges,70% of total billed charges,1531.73,75,,,percent of total billed charges,75% of total billed charges,1021.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1633.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1225.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1562.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1429.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1225.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,776.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1429.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2042.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1838.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.03,2042.3,
BONE CEMENT,3611720,CDM,278,RC,C1713,HCPCS,Outpatient,,,505.44,303.26,,90.98,18,,,percent of total billed charges,pays at 18% of total charges,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.81,70,,,percent of total billed charges,70% of total billed charges,379.08,75,,,percent of total billed charges,75% of total billed charges,252.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,404.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,505.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,353.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,505.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,505.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.2,505.44,
BONE GRAFT 1CC,3611721,CDM,278,RC,C1763,HCPCS,Outpatient,,,975,585,,175.5,18,,,percent of total billed charges,pays at 18% of total charges,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,167.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
BONE GRAFT 2.5CC,3611722,CDM,278,RC,C1763,HCPCS,Outpatient,,,2080,1248,,374.4,18,,,percent of total billed charges,pays at 18% of total charges,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456,70,,,percent of total billed charges,70% of total billed charges,1560,75,,,percent of total billed charges,75% of total billed charges,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1248,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2080,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,358.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1248,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,790.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,998.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.94,2080,
BONE GRAFT 5CC,3611723,CDM,278,RC,C1763,HCPCS,Outpatient,,,3900,2340,,702,18,,,percent of total billed charges,pays at 18% of total charges,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,70,,,percent of total billed charges,70% of total billed charges,2925,75,,,percent of total billed charges,75% of total billed charges,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,671.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1755,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1482,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.13,3900,
SYS INTERSPINOUS FIXATION,3611821,CDM,278,RC,C1821,HCPCS,Outpatient,,,6630,3978,,1193.4,18,,,percent of total billed charges,pays at 18% of total charges,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1193.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4641,70,,,percent of total billed charges,70% of total billed charges,4972.5,75,,,percent of total billed charges,75% of total billed charges,3315,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3978,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6630,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1142.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2983.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4641,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3978,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2519.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4641,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3182.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6630,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6630,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1038.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.92,6630,
PACK GYN,3611831,CDM,272,RC,,,Outpatient,,,163,97.8,,29.34,18,,,percent of total billed charges,pays at 18% of total charges,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.5,50,,,percent of total billed charges,pays at 50% of total billed charges,114.1,70,,,percent of total billed charges,70% of total billed charges,122.25,75,,,percent of total billed charges,75% of total billed charges,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,146.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.54,163,
BAG PRESSURE SM-MED,3612018,CDM,272,RC,,,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
SET ARTERIAL CATH,3612046,CDM,272,RC,,,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21,50,,,percent of total billed charges,pays at 50% of total billed charges,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
CATH OPERATIVE CHOLANG,3612047,CDM,272,RC,,,Outpatient,,,235,141,,42.3,18,,,percent of total billed charges,pays at 18% of total charges,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.5,50,,,percent of total billed charges,pays at 50% of total billed charges,164.5,70,,,percent of total billed charges,70% of total billed charges,176.25,75,,,percent of total billed charges,75% of total billed charges,117.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,164.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,211.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.82,235,
FEMORAL BONE BRUSH,3612048,CDM,272,RC,,,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
ARCH BARS,3612078,CDM,272,RC,,,Outpatient,,,161,96.6,,28.98,18,,,percent of total billed charges,pays at 18% of total charges,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.5,50,,,percent of total billed charges,pays at 50% of total billed charges,112.7,70,,,percent of total billed charges,70% of total billed charges,120.75,75,,,percent of total billed charges,75% of total billed charges,80.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.23,161,
CATH  EMBOLECTOMY,3612116,CDM,272,RC,C1757,HCPCS,Outpatient,,,184,110.4,,33.12,18,,,percent of total billed charges,pays at 18% of total charges,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,184,
CATH FOLEY,3612135,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
CATH MALECOT,3612165,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
CATH BARTHOLIN GLAND,3612166,CDM,272,RC,,,Outpatient,,,43.18,25.91,,7.77,18,,,percent of total billed charges,pays at 18% of total charges,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.59,50,,,percent of total billed charges,pays at 50% of total billed charges,30.23,70,,,percent of total billed charges,70% of total billed charges,32.39,75,,,percent of total billed charges,75% of total billed charges,21.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43.18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.77,43.18,
CATH MALECOT,3612174,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
CATH MUSHROOM,3612186,CDM,272,RC,,,Outpatient,,,62,37.2,,11.16,18,,,percent of total billed charges,pays at 18% of total charges,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,62,
CATH THORACIC,3612208,CDM,272,RC,,,Outpatient,,,71,42.6,,12.78,18,,,percent of total billed charges,pays at 18% of total charges,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.5,50,,,percent of total billed charges,pays at 50% of total billed charges,49.7,70,,,percent of total billed charges,70% of total billed charges,53.25,75,,,percent of total billed charges,75% of total billed charges,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.13,71,
CATH URET CONE,3612280,CDM,272,RC,C1758,HCPCS,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
CATH URET OLIVE TIP,3612306,CDM,272,RC,C1758,HCPCS,Outpatient,,,56.5,33.9,,10.17,18,,,percent of total billed charges,pays at 18% of total charges,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,56.5,
REPLIFORM TISSUE 2 X 7CM,3612311,CDM,278,RC,C1763,HCPCS,Outpatient,,,920,552,,165.6,18,,,percent of total billed charges,pays at 18% of total charges,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644,70,,,percent of total billed charges,70% of total billed charges,690,75,,,percent of total billed charges,75% of total billed charges,460,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,920,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,552,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,349.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,920,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,920,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.16,920,
CABLE W CRIMP,3612314,CDM,278,RC,C1713,HCPCS,Outpatient,,,661.5,396.9,,119.07,18,,,percent of total billed charges,pays at 18% of total charges,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.05,70,,,percent of total billed charges,70% of total billed charges,496.13,75,,,percent of total billed charges,75% of total billed charges,330.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,529.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,661.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,113.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,396.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,661.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,661.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.66,661.5,
CATH URET WHISTLE TIP,3612355,CDM,272,RC,C1758,HCPCS,Outpatient,,,55.5,33.3,,9.99,18,,,percent of total billed charges,pays at 18% of total charges,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.85,70,,,percent of total billed charges,70% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,27.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,55.5,
BONE ILIAC CREST WEDGE,3612427,CDM,278,RC,,,Outpatient,,,1626.5,975.9,,292.77,18,,,percent of total billed charges,pays at 18% of total charges,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,813.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1138.55,70,,,percent of total billed charges,70% of total billed charges,1219.88,75,,,percent of total billed charges,75% of total billed charges,813.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1301.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,975.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1626.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1138.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,618.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1138.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1626.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1626.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.87,1626.5,
SCREW BONE,3612435,CDM,278,RC,C1713,HCPCS,Outpatient,,,201.5,120.9,,36.27,18,,,percent of total billed charges,pays at 18% of total charges,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.05,70,,,percent of total billed charges,70% of total billed charges,151.13,75,,,percent of total billed charges,75% of total billed charges,100.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,201.5,
PROBE EHL,3612436,CDM,272,RC,,,Outpatient,,,513.5,308.1,,92.43,18,,,percent of total billed charges,pays at 18% of total charges,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.75,50,,,percent of total billed charges,pays at 50% of total billed charges,359.45,70,,,percent of total billed charges,70% of total billed charges,385.13,75,,,percent of total billed charges,75% of total billed charges,256.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,410.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,359.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,359.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,513.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,462.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.47,513.5,
CANNULA,3612438,CDM,272,RC,,,Outpatient,,,115.5,69.3,,20.79,18,,,percent of total billed charges,pays at 18% of total charges,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,50,,,percent of total billed charges,pays at 50% of total billed charges,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,57.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,115.5,
CANNULA BONE PORT,3612439,CDM,272,RC,,,Outpatient,,,734.5,440.7,,132.21,18,,,percent of total billed charges,pays at 18% of total charges,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.25,50,,,percent of total billed charges,pays at 50% of total billed charges,514.15,70,,,percent of total billed charges,70% of total billed charges,550.88,75,,,percent of total billed charges,75% of total billed charges,367.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,587.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,440.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,561.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,514.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,514.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,734.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,661.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.1,734.5,
PRESSURIZER CANAL SMALL,3612446,CDM,272,RC,,,Outpatient,,,47.5,28.5,,8.55,18,,,percent of total billed charges,pays at 18% of total charges,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.75,50,,,percent of total billed charges,pays at 50% of total billed charges,33.25,70,,,percent of total billed charges,70% of total billed charges,35.63,75,,,percent of total billed charges,75% of total billed charges,23.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,47.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,47.5,
CANNULA,3612453,CDM,272,RC,,,Outpatient,,,115.5,69.3,,20.79,18,,,percent of total billed charges,pays at 18% of total charges,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,50,,,percent of total billed charges,pays at 50% of total billed charges,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,57.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,115.5,
SHEATH PERITONEAL INTRO,3612455,CDM,272,RC,,,Outpatient,,,80.5,48.3,,14.49,18,,,percent of total billed charges,pays at 18% of total charges,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.25,50,,,percent of total billed charges,pays at 50% of total billed charges,56.35,70,,,percent of total billed charges,70% of total billed charges,60.38,75,,,percent of total billed charges,75% of total billed charges,40.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.61,80.5,
TUNNELING ROD,3612470,CDM,272,RC,,,Outpatient,,,283.5,170.1,,51.03,18,,,percent of total billed charges,pays at 18% of total charges,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,50,,,percent of total billed charges,pays at 50% of total billed charges,198.45,70,,,percent of total billed charges,70% of total billed charges,212.63,75,,,percent of total billed charges,75% of total billed charges,141.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,255.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,283.5,
FEMORAL COMPONENT,3612473,CDM,278,RC,C1776,HCPCS,Outpatient,,,3581.5,2148.9,,644.67,18,,,percent of total billed charges,pays at 18% of total charges,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,644.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2507.05,70,,,percent of total billed charges,70% of total billed charges,2686.13,75,,,percent of total billed charges,75% of total billed charges,1790.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2865.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2148.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3581.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,617.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1611.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2507.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2148.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1360.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2507.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3581.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3581.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.22,3581.5,
STAPLER PURSTRING 65,3612485,CDM,272,RC,,,Outpatient,,,274,164.4,,49.32,18,,,percent of total billed charges,pays at 18% of total charges,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,50,,,percent of total billed charges,pays at 50% of total billed charges,191.8,70,,,percent of total billed charges,70% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,137,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,274,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,274,
TIBIAL PLATE,3612489,CDM,278,RC,C1776,HCPCS,Outpatient,,,2748,1648.8,,494.64,18,,,percent of total billed charges,pays at 18% of total charges,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,494.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1923.6,70,,,percent of total billed charges,70% of total billed charges,2061,75,,,percent of total billed charges,75% of total billed charges,1374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1648.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2748,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,473.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1236.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1923.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1648.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1044.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1923.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1319.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2748,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2748,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.61,2748,
PATELLA,3612491,CDM,278,RC,C1776,HCPCS,Outpatient,,,1144.5,686.7,,206.01,18,,,percent of total billed charges,pays at 18% of total charges,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.15,70,,,percent of total billed charges,70% of total billed charges,858.38,75,,,percent of total billed charges,75% of total billed charges,572.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,915.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,686.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1144.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,197.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,801.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,686.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,801.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1144.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1144.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.34,1144.5,
ANCHORS BONE,3612511,CDM,278,RC,C1713,HCPCS,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,780,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
ANCHOR SUTURE,3612512,CDM,278,RC,C1713,HCPCS,Outpatient,,,457,274.2,,82.26,18,,,percent of total billed charges,pays at 18% of total charges,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.9,70,,,percent of total billed charges,70% of total billed charges,342.75,75,,,percent of total billed charges,75% of total billed charges,228.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,365.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,274.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,319.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,319.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,457,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,457,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.61,457,
ANCHOR SUTURE,3612513,CDM,278,RC,C1713,HCPCS,Outpatient,,,249,149.4,,44.82,18,,,percent of total billed charges,pays at 18% of total charges,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,124.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,249,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,249,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.02,249,
ANCHOR LEAD FASCIA,3612514,CDM,278,RC,,,Outpatient,,,438.75,263.25,,78.98,18,,,percent of total billed charges,pays at 18% of total charges,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.38,50,,,percent of total billed charges,pays at 50% of total billed charges,307.13,70,,,percent of total billed charges,70% of total billed charges,329.06,75,,,percent of total billed charges,75% of total billed charges,219.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,351,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,438.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,307.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,263.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,307.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,438.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,438.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.75,438.75,
ANCHOR SPINAL,3612515,CDM,278,RC,C1713,HCPCS,Outpatient,,,653.9,392.34,,117.7,18,,,percent of total billed charges,pays at 18% of total charges,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.73,70,,,percent of total billed charges,70% of total billed charges,490.43,75,,,percent of total billed charges,75% of total billed charges,326.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,523.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,392.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,653.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,457.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,392.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,457.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,653.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,653.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.47,653.9,
NAIL FEMORAL,3612516,CDM,278,RC,C1713,HCPCS,Outpatient,,,1912,1147.2,,344.16,18,,,percent of total billed charges,pays at 18% of total charges,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,344.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.4,70,,,percent of total billed charges,70% of total billed charges,1434,75,,,percent of total billed charges,75% of total billed charges,956,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1147.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1912,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,329.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,860.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1338.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1147.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,726.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1338.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1912,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1912,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.61,1912,
ANCHOR VERSALOK W/ORTHOCO,3612519,CDM,278,RC,C1713,HCPCS,Outpatient,,,516.5,309.9,,92.97,18,,,percent of total billed charges,pays at 18% of total charges,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.55,70,,,percent of total billed charges,70% of total billed charges,387.38,75,,,percent of total billed charges,75% of total billed charges,258.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,413.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,516.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,361.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,361.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,516.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,516.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.94,516.5,
SCREW BIOCOMPRESSION,3612521,CDM,278,RC,C1713,HCPCS,Outpatient,,,585,351,,105.3,18,,,percent of total billed charges,pays at 18% of total charges,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.5,70,,,percent of total billed charges,70% of total billed charges,438.75,75,,,percent of total billed charges,75% of total billed charges,292.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,585,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,585,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.67,585,
DRAIN PENROSE,3612550,CDM,272,RC,C1729,HCPCS,Outpatient,,,9,5.4,,1.62,18,,,percent of total billed charges,pays at 18% of total charges,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.3,70,,,percent of total billed charges,70% of total billed charges,6.75,75,,,percent of total billed charges,75% of total billed charges,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,9,
PIN STEINMAN,3612659,CDM,278,RC,C1713,HCPCS,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
DRILL BIT 4.0,3612667,CDM,272,RC,,,Outpatient,,,352,211.2,,63.36,18,,,percent of total billed charges,pays at 18% of total charges,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176,50,,,percent of total billed charges,pays at 50% of total billed charges,246.4,70,,,percent of total billed charges,70% of total billed charges,264,75,,,percent of total billed charges,75% of total billed charges,176,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,281.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,246.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,211.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,246.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,352,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,316.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.16,352,
SMOKE EVACUATION ATTACH,3612668,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
BLADE SPIRAL,3612681,CDM,278,RC,C1713,HCPCS,Outpatient,,,943,565.8,,169.74,18,,,percent of total billed charges,pays at 18% of total charges,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.1,70,,,percent of total billed charges,70% of total billed charges,707.25,75,,,percent of total billed charges,75% of total billed charges,471.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,565.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,943,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,660.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,565.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,660.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,943,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,943,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.77,943,
SLEEVE LCKG,3612683,CDM,272,RC,,,Outpatient,,,497.5,298.5,,89.55,18,,,percent of total billed charges,pays at 18% of total charges,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.75,50,,,percent of total billed charges,pays at 50% of total billed charges,348.25,70,,,percent of total billed charges,70% of total billed charges,373.13,75,,,percent of total billed charges,75% of total billed charges,248.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,398,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,348.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,497.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,447.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.96,497.5,
GUIDEWIRE ORTHO,3612684,CDM,272,RC,C1769,HCPCS,Outpatient,,,231,138.6,,41.58,18,,,percent of total billed charges,pays at 18% of total charges,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.25,75,,,percent of total billed charges,75% of total billed charges,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,231,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,207.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.2,231,
GUIDEWIRE ORTHO,3612685,CDM,272,RC,C1769,HCPCS,Outpatient,,,480,288,,86.4,18,,,percent of total billed charges,pays at 18% of total charges,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,75,,,percent of total billed charges,75% of total billed charges,240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,480,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.22,480,
NEEDLE MICRO DISS,3612687,CDM,272,RC,,,Outpatient,,,147,88.2,,26.46,18,,,percent of total billed charges,pays at 18% of total charges,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.5,50,,,percent of total billed charges,pays at 50% of total billed charges,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,73.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,147,
INSERT ARTICULAR,3612690,CDM,278,RC,C1776,HCPCS,Outpatient,,,4820.61,2892.37,,867.71,18,,,percent of total billed charges,pays at 18% of total charges,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,867.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3374.43,70,,,percent of total billed charges,70% of total billed charges,3615.46,75,,,percent of total billed charges,75% of total billed charges,2410.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3856.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2892.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4820.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,830.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2169.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3374.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2892.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1831.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3374.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2313.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4820.61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4820.61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.39,4820.61,
K WIRE DISP,3612806,CDM,272,RC,,,Outpatient,,,163.22,97.93,,29.38,18,,,percent of total billed charges,pays at 18% of total charges,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.61,50,,,percent of total billed charges,pays at 50% of total billed charges,114.25,70,,,percent of total billed charges,70% of total billed charges,122.42,75,,,percent of total billed charges,75% of total billed charges,81.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.22,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,146.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.58,163.22,
K WIRE,3612807,CDM,278,RC,C1713,HCPCS,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
TIBIAL PLATE,3612811,CDM,278,RC,C1776,HCPCS,Outpatient,,,3583.5,2150.1,,645.03,18,,,percent of total billed charges,pays at 18% of total charges,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,645.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2508.45,70,,,percent of total billed charges,70% of total billed charges,2687.63,75,,,percent of total billed charges,75% of total billed charges,1791.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2866.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2150.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3583.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,617.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1612.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2508.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2150.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1361.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2508.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3583.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3583.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.53,3583.5,
CUFF TOURNIQUET,3612814,CDM,272,RC,,,Outpatient,,,67,40.2,,12.06,18,,,percent of total billed charges,pays at 18% of total charges,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,50,,,percent of total billed charges,pays at 50% of total billed charges,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,67,
CUFF TOURNIQUET,3612815,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
SPECULUM SIGMOIDOSCOPE,3612823,CDM,272,RC,,,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
SUCTION IRRIGATOR,3612824,CDM,272,RC,,,Outpatient,,,301.5,180.9,,54.27,18,,,percent of total billed charges,pays at 18% of total charges,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.75,50,,,percent of total billed charges,pays at 50% of total billed charges,211.05,70,,,percent of total billed charges,70% of total billed charges,226.13,75,,,percent of total billed charges,75% of total billed charges,150.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,211.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,301.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,271.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,301.5,
CATH SUPRAPUB BONNANO,3612837,CDM,272,RC,C2627,HCPCS,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,125,
ADAPTER URETERAL,3612839,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
COMPONENT FEMORAL,3612841,CDM,278,RC,C1776,HCPCS,Outpatient,,,11800,7080,,2124,18,,,percent of total billed charges,pays at 18% of total charges,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2124,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8260,70,,,percent of total billed charges,70% of total billed charges,8850,75,,,percent of total billed charges,75% of total billed charges,5900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2033.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5310,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4484,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5664,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1849.06,11800,
PLATE ANGLED BLADE,3612860,CDM,278,RC,C1713,HCPCS,Outpatient,,,783.5,470.1,,141.03,18,,,percent of total billed charges,pays at 18% of total charges,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.45,70,,,percent of total billed charges,70% of total billed charges,587.63,75,,,percent of total billed charges,75% of total billed charges,391.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,626.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,470.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,783.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,548.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,470.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,548.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,783.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,783.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.77,783.5,
FEMORAL STEM,3612864,CDM,278,RC,C1776,HCPCS,Outpatient,,,8781,5268.6,,1580.58,18,,,percent of total billed charges,pays at 18% of total charges,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1580.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6146.7,70,,,percent of total billed charges,70% of total billed charges,6585.75,75,,,percent of total billed charges,75% of total billed charges,4390.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7024.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5268.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8781,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1512.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3951.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6146.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5268.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3336.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6146.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4214.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8781,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8781,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1375.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1375.98,8781,
CATH PERITONEAL,3612868,CDM,278,RC,C1750,HCPCS,Outpatient,,,252,151.2,,45.36,18,,,percent of total billed charges,pays at 18% of total charges,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,252,
TIBIAL INSERT,3612873,CDM,278,RC,C1776,HCPCS,Outpatient,,,4763,2857.8,,857.34,18,,,percent of total billed charges,pays at 18% of total charges,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,857.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3334.1,70,,,percent of total billed charges,70% of total billed charges,3572.25,75,,,percent of total billed charges,75% of total billed charges,2381.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3810.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2857.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4763,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,820.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2143.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3334.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2857.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1809.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3334.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2286.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4763,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4763,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,746.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.36,4763,
TWIST DRILL,3612874,CDM,272,RC,,,Outpatient,,,286.5,171.9,,51.57,18,,,percent of total billed charges,pays at 18% of total charges,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.25,50,,,percent of total billed charges,pays at 50% of total billed charges,200.55,70,,,percent of total billed charges,70% of total billed charges,214.88,75,,,percent of total billed charges,75% of total billed charges,143.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,229.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,286.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,257.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.89,286.5,
SPONGE TONSIL,3612892,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
SUTURE MONOCRYL,3612918,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
LAP ENDOSTITCH,3612998,CDM,270,RC,,,Outpatient,,,302.5,181.5,,54.45,18,,,percent of total billed charges,pays at 18% of total charges,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.25,50,,,percent of total billed charges,pays at 50% of total billed charges,211.75,70,,,percent of total billed charges,70% of total billed charges,226.88,75,,,percent of total billed charges,75% of total billed charges,151.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,211.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,272.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.4,302.5,
KIT TRANSURETHRAL DELIVERY,3613019,CDM,272,RC,,,Outpatient,,,85,51,,15.3,18,,,percent of total billed charges,pays at 18% of total charges,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.5,50,,,percent of total billed charges,pays at 50% of total billed charges,59.5,70,,,percent of total billed charges,70% of total billed charges,63.75,75,,,percent of total billed charges,75% of total billed charges,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,85,
BANDAGE KNEE ROLL,3613021,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
NEEDLE W TROCAR STYLET,3613044,CDM,272,RC,,,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
RESERVOIR SALMON-RICKHAM,3613047,CDM,278,RC,C1889,HCPCS,Outpatient,,,440,264,,79.2,18,,,percent of total billed charges,pays at 18% of total charges,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,220,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,440,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,440,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,440,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.95,440,
RODS,3613051,CDM,272,RC,,,Outpatient,,,673,403.8,,121.14,18,,,percent of total billed charges,pays at 18% of total charges,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,336.5,50,,,percent of total billed charges,pays at 50% of total billed charges,471.1,70,,,percent of total billed charges,70% of total billed charges,504.75,75,,,percent of total billed charges,75% of total billed charges,336.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,403.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,514.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,471.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,403.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,471.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,605.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.46,673,
HUMERAL BODY,3613058,CDM,278,RC,C1776,HCPCS,Outpatient,,,1433.25,859.95,,257.99,18,,,percent of total billed charges,pays at 18% of total charges,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.28,70,,,percent of total billed charges,70% of total billed charges,1074.94,75,,,percent of total billed charges,75% of total billed charges,716.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1146.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,859.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1433.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1003.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,859.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,544.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1003.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,687.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1433.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1433.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.59,1433.25,
DRILL BIT 3.2,3613066,CDM,272,RC,,,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.5,50,,,percent of total billed charges,pays at 50% of total billed charges,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,333,
CATH URET,3613101,CDM,272,RC,C1758,HCPCS,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
CATH COUNCIL,3613102,CDM,272,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
SPLINT CUST FIBER 2 IN,3613103,CDM,271,RC,,,Outpatient,,,7.35,4.41,,1.32,18,,,percent of total billed charges,pays at 18% of total charges,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.68,50,,,percent of total billed charges,pays at 50% of total billed charges,5.15,70,,,percent of total billed charges,70% of total billed charges,5.51,75,,,percent of total billed charges,75% of total billed charges,3.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.15,7.35,
SYS EXT FIX DIGIT WIDGET,3613108,CDM,272,RC,,,Outpatient,,,2113,1267.8,,380.34,18,,,percent of total billed charges,pays at 18% of total charges,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1056.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1479.1,70,,,percent of total billed charges,70% of total billed charges,1584.75,75,,,percent of total billed charges,75% of total billed charges,1056.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1690.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1267.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1616.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1479.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1267.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1479.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2113,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1901.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.11,2113,
ACETABULAR LCKG RING,3613115,CDM,278,RC,C1776,HCPCS,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
RING CAPSULAR TENSION,3613116,CDM,278,RC,,,Outpatient,,,340,204,,61.2,18,,,percent of total billed charges,pays at 18% of total charges,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170,50,,,percent of total billed charges,pays at 50% of total billed charges,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
SET INTRODUCER,3613135,CDM,272,RC,,,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,50,,,percent of total billed charges,pays at 50% of total billed charges,59.85,70,,,percent of total billed charges,70% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
CLIP ANEURSYM,3613148,CDM,272,RC,,,Outpatient,,,793,475.8,,142.74,18,,,percent of total billed charges,pays at 18% of total charges,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.5,50,,,percent of total billed charges,pays at 50% of total billed charges,555.1,70,,,percent of total billed charges,70% of total billed charges,594.75,75,,,percent of total billed charges,75% of total billed charges,396.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,475.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,606.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,555.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,475.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,555.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,793,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,713.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.26,793,
PLATE DCP 6H TO 10H,3613150,CDM,278,RC,C1713,HCPCS,Outpatient,,,256.5,153.9,,46.17,18,,,percent of total billed charges,pays at 18% of total charges,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.55,70,,,percent of total billed charges,70% of total billed charges,192.38,75,,,percent of total billed charges,75% of total billed charges,128.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,179.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,256.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.19,256.5,
ROD STRAIGHT,3613159,CDM,278,RC,C1713,HCPCS,Outpatient,,,832,499.2,,149.76,18,,,percent of total billed charges,pays at 18% of total charges,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.4,70,,,percent of total billed charges,70% of total billed charges,624,75,,,percent of total billed charges,75% of total billed charges,416,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,665.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,499.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,832,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,582.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,499.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,582.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,832,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,832,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.37,832,
KNIFE ENDO CARPAL TUNNEL,3613166,CDM,272,RC,,,Outpatient,,,122,73.2,,21.96,18,,,percent of total billed charges,pays at 18% of total charges,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61,50,,,percent of total billed charges,pays at 50% of total billed charges,85.4,70,,,percent of total billed charges,70% of total billed charges,91.5,75,,,percent of total billed charges,75% of total billed charges,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,122,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.12,122,
DRILL BIT,3613167,CDM,272,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
IMPLANT SHOULDER BALLON,3613171,CDM,278,RC,C1776,HCPCS,Outpatient,,,8840,5304,,1591.2,18,,,percent of total billed charges,pays at 18% of total charges,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1591.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6188,70,,,percent of total billed charges,70% of total billed charges,6630,75,,,percent of total billed charges,75% of total billed charges,4420,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7072,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5304,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8840,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1523.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3978,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5304,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3359.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6188,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4243.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8840,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8840,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1385.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1385.23,8840,
TUBING BYPASS,3613180,CDM,272,RC,,,Outpatient,,,64,38.4,,11.52,18,,,percent of total billed charges,pays at 18% of total charges,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32,50,,,percent of total billed charges,pays at 50% of total billed charges,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,64,
IMPLANT OCULAR,3613184,CDM,278,RC,C1783,HCPCS,Outpatient,,,91.5,54.9,,16.47,18,,,percent of total billed charges,pays at 18% of total charges,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.05,70,,,percent of total billed charges,70% of total billed charges,68.63,75,,,percent of total billed charges,75% of total billed charges,45.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,91.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,91.5,
TIBIAL TRAY,3613188,CDM,278,RC,C1776,HCPCS,Outpatient,,,3229,1937.4,,581.22,18,,,percent of total billed charges,pays at 18% of total charges,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2260.3,70,,,percent of total billed charges,70% of total billed charges,2421.75,75,,,percent of total billed charges,75% of total billed charges,1614.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2583.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1937.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3229,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,556.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1453.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2260.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1937.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1227.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2260.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1549.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,505.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.98,3229,
BUR FULL RADIUS,3613210,CDM,272,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
ADAPTER HEMOSTASIS VALVE,3613211,CDM,272,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
BONE FIBULA GRAFT,3613215,CDM,278,RC,,,Outpatient,,,849.5,509.7,,152.91,18,,,percent of total billed charges,pays at 18% of total charges,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,424.75,50,,,percent of total billed charges,pays at 50% of total billed charges,594.65,70,,,percent of total billed charges,70% of total billed charges,637.13,75,,,percent of total billed charges,75% of total billed charges,424.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,679.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,849.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,594.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,509.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,594.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,849.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.12,849.5,
STAPLER ROTIC 30 4.8,3613216,CDM,272,RC,,,Outpatient,,,923,553.8,,166.14,18,,,percent of total billed charges,pays at 18% of total charges,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,461.5,50,,,percent of total billed charges,pays at 50% of total billed charges,646.1,70,,,percent of total billed charges,70% of total billed charges,692.25,75,,,percent of total billed charges,75% of total billed charges,461.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,738.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,553.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,706.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,646.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,553.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,350.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,646.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,923,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,830.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.63,923,
K WIRE THRD,3613222,CDM,278,RC,C1713,HCPCS,Outpatient,,,89.5,53.7,,16.11,18,,,percent of total billed charges,pays at 18% of total charges,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,44.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
SCREW CORTEX 4.5,3613231,CDM,278,RC,C1713,HCPCS,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
MENISCUS MENDER II,3613241,CDM,272,RC,,,Outpatient,,,240.5,144.3,,43.29,18,,,percent of total billed charges,pays at 18% of total charges,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.25,50,,,percent of total billed charges,pays at 50% of total billed charges,168.35,70,,,percent of total billed charges,70% of total billed charges,180.38,75,,,percent of total billed charges,75% of total billed charges,120.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,216.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,240.5,
DRILL BIT,3613247,CDM,272,RC,,,Outpatient,,,412.5,247.5,,74.25,18,,,percent of total billed charges,pays at 18% of total charges,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.25,50,,,percent of total billed charges,pays at 50% of total billed charges,288.75,70,,,percent of total billed charges,70% of total billed charges,309.38,75,,,percent of total billed charges,75% of total billed charges,206.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,288.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,288.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,412.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,371.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.64,412.5,
PLATE WRIST,3613248,CDM,278,RC,C1713,HCPCS,Outpatient,,,1681,1008.6,,302.58,18,,,percent of total billed charges,pays at 18% of total charges,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.7,70,,,percent of total billed charges,70% of total billed charges,1260.75,75,,,percent of total billed charges,75% of total billed charges,840.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1008.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1681,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,289.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,638.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1176.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1681,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1681,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.41,1681,
SET BERKELEY COLLECT,3613249,CDM,272,RC,,,Outpatient,,,31.5,18.9,,5.67,18,,,percent of total billed charges,pays at 18% of total charges,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,50,,,percent of total billed charges,pays at 50% of total billed charges,22.05,70,,,percent of total billed charges,70% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,15.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,31.5,
CATH NEPHROSTOMY,3613251,CDM,272,RC,,,Outpatient,,,213,127.8,,38.34,18,,,percent of total billed charges,pays at 18% of total charges,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.5,50,,,percent of total billed charges,pays at 50% of total billed charges,149.1,70,,,percent of total billed charges,70% of total billed charges,159.75,75,,,percent of total billed charges,75% of total billed charges,106.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,149.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,213,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,191.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.38,213,
CATH NEPHROSTOMY,3613255,CDM,272,RC,,,Outpatient,,,527.8,316.68,,95,18,,,percent of total billed charges,pays at 18% of total charges,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,263.9,50,,,percent of total billed charges,pays at 50% of total billed charges,369.46,70,,,percent of total billed charges,70% of total billed charges,395.85,75,,,percent of total billed charges,75% of total billed charges,263.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,403.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.51,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,369.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,369.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,527.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,475.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.71,527.8,
PLATE ADAPTION,3613283,CDM,278,RC,C1713,HCPCS,Outpatient,,,702.5,421.5,,126.45,18,,,percent of total billed charges,pays at 18% of total charges,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.75,70,,,percent of total billed charges,70% of total billed charges,526.88,75,,,percent of total billed charges,75% of total billed charges,351.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,562,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,421.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,702.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,491.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,421.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,491.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,702.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,702.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.08,702.5,
PLATE Y,3613290,CDM,278,RC,C1713,HCPCS,Outpatient,,,868.5,521.1,,156.33,18,,,percent of total billed charges,pays at 18% of total charges,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,607.95,70,,,percent of total billed charges,70% of total billed charges,651.38,75,,,percent of total billed charges,75% of total billed charges,434.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,694.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,521.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,868.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,607.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,521.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,607.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,868.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,868.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.09,868.5,
PLATE H,3613291,CDM,278,RC,C1713,HCPCS,Outpatient,,,852.5,511.5,,153.45,18,,,percent of total billed charges,pays at 18% of total charges,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.75,70,,,percent of total billed charges,70% of total billed charges,639.38,75,,,percent of total billed charges,75% of total billed charges,426.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,682,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,511.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,596.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,511.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,596.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,852.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,852.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.59,852.5,
PLATE 6H 3.5 RECON,3613293,CDM,278,RC,C1713,HCPCS,Outpatient,,,511.5,306.9,,92.07,18,,,percent of total billed charges,pays at 18% of total charges,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.05,70,,,percent of total billed charges,70% of total billed charges,383.63,75,,,percent of total billed charges,75% of total billed charges,255.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,409.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,511.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,358.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,358.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,511.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,511.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.15,511.5,
KIT MICROSENSOR NEURO,3613303,CDM,272,RC,,,Outpatient,,,1345,807,,242.1,18,,,percent of total billed charges,pays at 18% of total charges,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,672.5,50,,,percent of total billed charges,pays at 50% of total billed charges,941.5,70,,,percent of total billed charges,70% of total billed charges,1008.75,75,,,percent of total billed charges,75% of total billed charges,672.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1076,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,807,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1028.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,941.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,807,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,511.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,941.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1345,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1210.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.76,1345,
LIGAMENT CHISEL,3613305,CDM,272,RC,,,Outpatient,,,275,165,,49.5,18,,,percent of total billed charges,pays at 18% of total charges,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,275,
NAIL TIBIAL,3613307,CDM,278,RC,C1713,HCPCS,Outpatient,,,1760,1056,,316.8,18,,,percent of total billed charges,pays at 18% of total charges,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1232,70,,,percent of total billed charges,70% of total billed charges,1320,75,,,percent of total billed charges,75% of total billed charges,880,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1056,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1760,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,303.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,792,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1232,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1056,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,668.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1232,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.79,1760,
TIBIAL INSERT,3613309,CDM,278,RC,C1776,HCPCS,Outpatient,,,1111,666.6,,199.98,18,,,percent of total billed charges,pays at 18% of total charges,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.7,70,,,percent of total billed charges,70% of total billed charges,833.25,75,,,percent of total billed charges,75% of total billed charges,555.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,888.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,666.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1111,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,191.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,777.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,666.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,777.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,533.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1111,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1111,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.09,1111,
FEMORAL HEAD,3613450,CDM,278,RC,C1776,HCPCS,Outpatient,,,5917.5,3550.5,,1065.15,18,,,percent of total billed charges,pays at 18% of total charges,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1065.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4142.25,70,,,percent of total billed charges,70% of total billed charges,4438.13,75,,,percent of total billed charges,75% of total billed charges,2958.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4734,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3550.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5917.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1019.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2662.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4142.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3550.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2248.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4142.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2840.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5917.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5917.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,927.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.27,5917.5,
ACETABALAR CUP/SHELL,3613453,CDM,278,RC,C1713,HCPCS,Outpatient,,,8586,5151.6,,1545.48,18,,,percent of total billed charges,pays at 18% of total charges,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1545.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6010.2,70,,,percent of total billed charges,70% of total billed charges,6439.5,75,,,percent of total billed charges,75% of total billed charges,4293,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5151.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8586,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1479.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3863.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6010.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5151.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3262.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6010.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4121.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8586,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8586,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1345.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.43,8586,
SUTURE PDS CLEAR,3613509,CDM,272,RC,,,Outpatient,,,35,21,,6.3,18,,,percent of total billed charges,pays at 18% of total charges,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.5,50,,,percent of total billed charges,pays at 50% of total billed charges,24.5,70,,,percent of total billed charges,70% of total billed charges,26.25,75,,,percent of total billed charges,75% of total billed charges,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,35,
SUTURE VICRYL CR,3613532,CDM,272,RC,,,Outpatient,,,67,40.2,,12.06,18,,,percent of total billed charges,pays at 18% of total charges,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,50,,,percent of total billed charges,pays at 50% of total billed charges,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,67,
SUTURE VICRYL MONO,3613549,CDM,270,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
SUTURE SURGILENE,3613564,CDM,270,RC,,,Outpatient,,,152.5,91.5,,27.45,18,,,percent of total billed charges,pays at 18% of total charges,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.25,50,,,percent of total billed charges,pays at 50% of total billed charges,106.75,70,,,percent of total billed charges,70% of total billed charges,114.38,75,,,percent of total billed charges,75% of total billed charges,76.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.9,152.5,
DRAIN SURETRANS,3613574,CDM,272,RC,C1729,HCPCS,Outpatient,,,326.5,195.9,,58.77,18,,,percent of total billed charges,pays at 18% of total charges,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.55,70,,,percent of total billed charges,70% of total billed charges,244.88,75,,,percent of total billed charges,75% of total billed charges,163.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,228.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,228.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,293.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.16,326.5,
SCREW LCKG,3613577,CDM,278,RC,C1713,HCPCS,Outpatient,,,264.5,158.7,,47.61,18,,,percent of total billed charges,pays at 18% of total charges,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.15,70,,,percent of total billed charges,70% of total billed charges,198.38,75,,,percent of total billed charges,75% of total billed charges,132.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,211.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,185.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,185.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,264.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,264.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.45,264.5,
CEMENT MOLD TIBIAL,3613581,CDM,272,RC,,,Outpatient,,,1686.1,1011.66,,303.5,18,,,percent of total billed charges,pays at 18% of total charges,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.05,50,,,percent of total billed charges,pays at 50% of total billed charges,1180.27,70,,,percent of total billed charges,70% of total billed charges,1264.58,75,,,percent of total billed charges,75% of total billed charges,843.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1348.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1011.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1289.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1180.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1011.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,640.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1180.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1517.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.21,1686.1,
BLADE SAW,3613582,CDM,272,RC,,,Outpatient,,,37,22.2,,6.66,18,,,percent of total billed charges,pays at 18% of total charges,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.5,50,,,percent of total billed charges,pays at 50% of total billed charges,25.9,70,,,percent of total billed charges,70% of total billed charges,27.75,75,,,percent of total billed charges,75% of total billed charges,18.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,33.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,37,
TIBIAL COMPONENT,3613585,CDM,278,RC,C1776,HCPCS,Outpatient,,,3893,2335.8,,700.74,18,,,percent of total billed charges,pays at 18% of total charges,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,700.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2725.1,70,,,percent of total billed charges,70% of total billed charges,2919.75,75,,,percent of total billed charges,75% of total billed charges,1946.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2335.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3893,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,670.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1751.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2725.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2335.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1479.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2725.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1868.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3893,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3893,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,610.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.03,3893,
BLADE SAW MANDIBULAR,3613587,CDM,272,RC,,,Outpatient,,,487,292.2,,87.66,18,,,percent of total billed charges,pays at 18% of total charges,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.5,50,,,percent of total billed charges,pays at 50% of total billed charges,340.9,70,,,percent of total billed charges,70% of total billed charges,365.25,75,,,percent of total billed charges,75% of total billed charges,243.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,389.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,340.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,340.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,487,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,438.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,487,
SYSTEM KNEE COMPLETE,3613590,CDM,278,RC,C1776,HCPCS,Outpatient,,,2513.23,1507.94,,452.38,18,,,percent of total billed charges,pays at 18% of total charges,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1759.26,70,,,percent of total billed charges,70% of total billed charges,1884.92,75,,,percent of total billed charges,75% of total billed charges,1256.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2010.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1507.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2513.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,433.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1759.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1507.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,955.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1759.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2513.23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2513.23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.82,2513.23,
COMPONENT TIBIAL REPLACEMENT,3613591,CDM,278,RC,C1776,HCPCS,Outpatient,,,13005.98,7803.59,,2341.08,18,,,percent of total billed charges,pays at 18% of total charges,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2341.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9104.19,70,,,percent of total billed charges,70% of total billed charges,9754.49,75,,,percent of total billed charges,75% of total billed charges,6502.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10404.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7803.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13005.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2240.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5852.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7803.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4942.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9104.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6242.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13005.98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13005.98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.04,13005.98,
COMPONENT TIBIAL,3613592,CDM,278,RC,C1776,HCPCS,Outpatient,,,17279.37,10367.62,,3110.29,18,,,percent of total billed charges,pays at 18% of total charges,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3110.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12095.56,70,,,percent of total billed charges,70% of total billed charges,12959.53,75,,,percent of total billed charges,75% of total billed charges,8639.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13823.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10367.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17279.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2977.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7775.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12095.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10367.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6566.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12095.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8294.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17279.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17279.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2707.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2707.68,17279.37,
COMPONENT TIBIAL SEGMENT,3613594,CDM,278,RC,C1776,HCPCS,Outpatient,,,10882.87,6529.72,,1958.92,18,,,percent of total billed charges,pays at 18% of total charges,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1958.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7618.01,70,,,percent of total billed charges,70% of total billed charges,8162.15,75,,,percent of total billed charges,75% of total billed charges,5441.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8706.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6529.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10882.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1875.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4897.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7618.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6529.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4135.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7618.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10882.87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10882.87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1705.35,10882.87,
COMPONENT TIBIAL,3613595,CDM,278,RC,C1776,HCPCS,Outpatient,,,8672.26,5203.36,,1561.01,18,,,percent of total billed charges,pays at 18% of total charges,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1561.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6070.58,70,,,percent of total billed charges,70% of total billed charges,6504.2,75,,,percent of total billed charges,75% of total billed charges,4336.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6937.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5203.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8672.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1494.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3902.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6070.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5203.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3295.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6070.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4162.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8672.26,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8672.26,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1358.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1358.94,8672.26,
COMPONENT TIBIAL HINGED,3613596,CDM,278,RC,C1776,HCPCS,Outpatient,,,2947.87,1768.72,,530.62,18,,,percent of total billed charges,pays at 18% of total charges,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2063.51,70,,,percent of total billed charges,70% of total billed charges,2210.9,75,,,percent of total billed charges,75% of total billed charges,1473.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2358.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1768.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2947.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,507.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2063.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1768.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1120.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2063.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1414.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2947.87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2947.87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,461.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.93,2947.87,
DERMATOME HEAD DISP,3613621,CDM,272,RC,,,Outpatient,,,82,49.2,,14.76,18,,,percent of total billed charges,pays at 18% of total charges,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41,50,,,percent of total billed charges,pays at 50% of total billed charges,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,82,
BLADE SAW,3613635,CDM,272,RC,,,Outpatient,,,233,139.8,,41.94,18,,,percent of total billed charges,pays at 18% of total charges,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.5,50,,,percent of total billed charges,pays at 50% of total billed charges,163.1,70,,,percent of total billed charges,70% of total billed charges,174.75,75,,,percent of total billed charges,75% of total billed charges,116.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,163.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,233,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,209.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.51,233,
LOOPS VESSEL,3613657,CDM,272,RC,,,Outpatient,,,13.5,8.1,,2.43,18,,,percent of total billed charges,pays at 18% of total charges,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.75,50,,,percent of total billed charges,pays at 50% of total billed charges,9.45,70,,,percent of total billed charges,70% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,13.5,
STIMULATOR OSTEOGEN,3613662,CDM,278,RC,C1778,HCPCS,Outpatient,,,9025,5415,,1624.5,18,,,percent of total billed charges,pays at 18% of total charges,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1624.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6317.5,70,,,percent of total billed charges,70% of total billed charges,6768.75,75,,,percent of total billed charges,75% of total billed charges,4512.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5415,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9025,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1555.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4061.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6317.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5415,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3429.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6317.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4332,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1414.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1414.22,9025,
BATTERY NEUROSTM GEN IMPLTBL,3613663,CDM,278,RC,C1767,HCPCS,Outpatient,,,16893.5,10136.1,,3040.83,18,,,percent of total billed charges,pays at 18% of total charges,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3040.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11825.45,70,,,percent of total billed charges,70% of total billed charges,12670.13,75,,,percent of total billed charges,75% of total billed charges,8446.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10136.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16893.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2910.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7602.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11825.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10136.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6419.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11825.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8108.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16893.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16893.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2647.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2647.21,16893.5,
BATTERY PACK DISP,3613665,CDM,272,RC,,,Outpatient,,,387,232.2,,69.66,18,,,percent of total billed charges,pays at 18% of total charges,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.5,50,,,percent of total billed charges,pays at 50% of total billed charges,270.9,70,,,percent of total billed charges,70% of total billed charges,290.25,75,,,percent of total billed charges,75% of total billed charges,193.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,270.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,270.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,387,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,348.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.64,387,
PEN SMOKE VAC W/ACE BLADE,3613673,CDM,272,RC,,,Outpatient,,,208,124.8,,37.44,18,,,percent of total billed charges,pays at 18% of total charges,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104,50,,,percent of total billed charges,pays at 50% of total billed charges,145.6,70,,,percent of total billed charges,70% of total billed charges,156,75,,,percent of total billed charges,75% of total billed charges,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,208,
LEAD PISCES QUAD PLUS,3613675,CDM,278,RC,C1778,HCPCS,Outpatient,,,3761,2256.6,,676.98,18,,,percent of total billed charges,pays at 18% of total charges,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,676.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2632.7,70,,,percent of total billed charges,70% of total billed charges,2820.75,75,,,percent of total billed charges,75% of total billed charges,1880.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3008.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2256.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3761,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,648.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1692.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2632.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2256.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1429.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2632.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1805.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3761,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3761,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.35,3761,
CANNULA VESSEL,3613677,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
KIT CANNULA THRD,3613691,CDM,272,RC,,,Outpatient,,,86,51.6,,15.48,18,,,percent of total billed charges,pays at 18% of total charges,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43,50,,,percent of total billed charges,pays at 50% of total billed charges,60.2,70,,,percent of total billed charges,70% of total billed charges,64.5,75,,,percent of total billed charges,75% of total billed charges,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,86,
SUTURE PLEDGET PFTE,3613697,CDM,272,RC,,,Outpatient,,,20.18,12.11,,3.63,18,,,percent of total billed charges,pays at 18% of total charges,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.09,50,,,percent of total billed charges,pays at 50% of total billed charges,14.13,70,,,percent of total billed charges,70% of total billed charges,15.14,75,,,percent of total billed charges,75% of total billed charges,10.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.16,20.18,
SUTURE PLEDGET,3613698,CDM,272,RC,,,Outpatient,,,90,54,,16.2,18,,,percent of total billed charges,pays at 18% of total charges,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,50,,,percent of total billed charges,pays at 50% of total billed charges,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,90,
WASHER LGE,3613709,CDM,278,RC,C1713,HCPCS,Outpatient,,,55.5,33.3,,9.99,18,,,percent of total billed charges,pays at 18% of total charges,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.85,70,,,percent of total billed charges,70% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,27.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,55.5,
HOOD STACKHOUSE LENS,3613740,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
TIBIAL PLATE,3613742,CDM,278,RC,C1776,HCPCS,Outpatient,,,1356,813.6,,244.08,18,,,percent of total billed charges,pays at 18% of total charges,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.2,70,,,percent of total billed charges,70% of total billed charges,1017,75,,,percent of total billed charges,75% of total billed charges,678,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1084.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,813.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1356,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,233.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,949.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,813.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,949.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1356,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1356,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.49,1356,
TIBIAL BASEPLATE HINGED,3613745,CDM,278,RC,C1776,HCPCS,Outpatient,,,6426,3855.6,,1156.68,18,,,percent of total billed charges,pays at 18% of total charges,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1156.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4498.2,70,,,percent of total billed charges,70% of total billed charges,4819.5,75,,,percent of total billed charges,75% of total billed charges,3213,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3855.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6426,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1107.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2891.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4498.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3855.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2441.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4498.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3084.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6426,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6426,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1006.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.95,6426,
PLUG BONE,3613758,CDM,272,RC,,,Outpatient,,,69.5,41.7,,12.51,18,,,percent of total billed charges,pays at 18% of total charges,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.75,50,,,percent of total billed charges,pays at 50% of total billed charges,48.65,70,,,percent of total billed charges,70% of total billed charges,52.13,75,,,percent of total billed charges,75% of total billed charges,34.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,48.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,69.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,62.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.89,69.5,
WALKER SHORT LEG MED,3613762,CDM,272,RC,,,Outpatient,,,251,150.6,,45.18,18,,,percent of total billed charges,pays at 18% of total charges,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.5,50,,,percent of total billed charges,pays at 50% of total billed charges,175.7,70,,,percent of total billed charges,70% of total billed charges,188.25,75,,,percent of total billed charges,75% of total billed charges,125.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,251,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.33,251,
PATELLA,3613770,CDM,278,RC,C1776,HCPCS,Outpatient,,,409.5,245.7,,73.71,18,,,percent of total billed charges,pays at 18% of total charges,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,70,,,percent of total billed charges,70% of total billed charges,307.13,75,,,percent of total billed charges,75% of total billed charges,204.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,327.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,409.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.17,409.5,
LCKG SCREW,3613774,CDM,278,RC,C1713,HCPCS,Outpatient,,,203.5,122.1,,36.63,18,,,percent of total billed charges,pays at 18% of total charges,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.45,70,,,percent of total billed charges,70% of total billed charges,152.63,75,,,percent of total billed charges,75% of total billed charges,101.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.89,203.5,
TIBIAL TRAY,3613775,CDM,278,RC,C1776,HCPCS,Outpatient,,,1001,600.6,,180.18,18,,,percent of total billed charges,pays at 18% of total charges,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.7,70,,,percent of total billed charges,70% of total billed charges,750.75,75,,,percent of total billed charges,75% of total billed charges,500.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1001,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,700.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,600.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,700.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1001,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1001,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.86,1001,
PATCH CARIOVASCULAR,3613780,CDM,278,RC,C1768,HCPCS,Outpatient,,,451.62,270.97,,81.29,18,,,percent of total billed charges,pays at 18% of total charges,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.13,70,,,percent of total billed charges,70% of total billed charges,338.72,75,,,percent of total billed charges,75% of total billed charges,225.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,361.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,451.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,316.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,451.62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,451.62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.77,451.62,
PATCH PERICARDIUM,3613782,CDM,278,RC,C1768,HCPCS,Outpatient,,,638.3,382.98,,114.89,18,,,percent of total billed charges,pays at 18% of total charges,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.81,70,,,percent of total billed charges,70% of total billed charges,478.73,75,,,percent of total billed charges,75% of total billed charges,319.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,638.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,446.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,446.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,638.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,638.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.02,638.3,
INSERTER DISPOSABLE,3613787,CDM,272,RC,,,Outpatient,,,775,465,,139.5,18,,,percent of total billed charges,pays at 18% of total charges,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.5,50,,,percent of total billed charges,pays at 50% of total billed charges,542.5,70,,,percent of total billed charges,70% of total billed charges,581.25,75,,,percent of total billed charges,75% of total billed charges,387.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,465,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,542.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,465,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,542.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,775,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,697.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.44,775,
PIN RUSH,3613791,CDM,278,RC,C1713,HCPCS,Outpatient,,,135,81,,24.3,18,,,percent of total billed charges,pays at 18% of total charges,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,135,
SET TUR,3613850,CDM,272,RC,,,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
BLADE BEAVER MICROSHARP,3613863,CDM,272,RC,,,Outpatient,,,21,12.6,,3.78,18,,,percent of total billed charges,pays at 18% of total charges,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,21,
BUR OVAL,3613864,CDM,272,RC,,,Outpatient,,,139.5,83.7,,25.11,18,,,percent of total billed charges,pays at 18% of total charges,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.75,50,,,percent of total billed charges,pays at 50% of total billed charges,97.65,70,,,percent of total billed charges,70% of total billed charges,104.63,75,,,percent of total billed charges,75% of total billed charges,69.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,97.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,139.5,
FILTER PALL BLOOD,3613865,CDM,272,RC,,,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21,50,,,percent of total billed charges,pays at 50% of total billed charges,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
BLOOD PACK,3613866,CDM,272,RC,,,Outpatient,,,18.5,11.1,,3.33,18,,,percent of total billed charges,pays at 18% of total charges,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.25,50,,,percent of total billed charges,pays at 50% of total billed charges,12.95,70,,,percent of total billed charges,70% of total billed charges,13.88,75,,,percent of total billed charges,75% of total billed charges,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,18.5,
BAG AUTOTRANSFUSION,3613867,CDM,272,RC,,,Outpatient,,,77,46.2,,13.86,18,,,percent of total billed charges,pays at 18% of total charges,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.5,50,,,percent of total billed charges,pays at 50% of total billed charges,53.9,70,,,percent of total billed charges,70% of total billed charges,57.75,75,,,percent of total billed charges,75% of total billed charges,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.07,77,
CANNULA TWIST-IN,3613869,CDM,272,RC,,,Outpatient,,,105,63,,18.9,18,,,percent of total billed charges,pays at 18% of total charges,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,50,,,percent of total billed charges,pays at 50% of total billed charges,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,105,
SET-URINARY-DRAINAGE,3613870,CDM,272,RC,,,Outpatient,,,32.5,19.5,,5.85,18,,,percent of total billed charges,pays at 18% of total charges,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.25,50,,,percent of total billed charges,pays at 50% of total billed charges,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,16.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,32.5,
SHUNT CTS FLOCOIL,3613922,CDM,272,RC,,,Outpatient,,,263.5,158.1,,47.43,18,,,percent of total billed charges,pays at 18% of total charges,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.75,50,,,percent of total billed charges,pays at 50% of total billed charges,184.45,70,,,percent of total billed charges,70% of total billed charges,197.63,75,,,percent of total billed charges,75% of total billed charges,131.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,184.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,263.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,237.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.29,263.5,
GLENOID FIN GLOBAL,3613924,CDM,278,RC,C1776,HCPCS,Outpatient,,,1879,1127.4,,338.22,18,,,percent of total billed charges,pays at 18% of total charges,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,338.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1315.3,70,,,percent of total billed charges,70% of total billed charges,1409.25,75,,,percent of total billed charges,75% of total billed charges,939.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1503.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1127.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1879,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,323.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,845.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1315.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1127.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,714.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1315.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,901.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1879,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1879,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.44,1879,
JURGAN BALL,3613936,CDM,272,RC,,,Outpatient,,,75.5,45.3,,13.59,18,,,percent of total billed charges,pays at 18% of total charges,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.75,50,,,percent of total billed charges,pays at 50% of total billed charges,52.85,70,,,percent of total billed charges,70% of total billed charges,56.63,75,,,percent of total billed charges,75% of total billed charges,37.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,75.5,
SCREW CANN 3.5,3613941,CDM,278,RC,C1713,HCPCS,Outpatient,,,299.5,179.7,,53.91,18,,,percent of total billed charges,pays at 18% of total charges,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.65,70,,,percent of total billed charges,70% of total billed charges,224.63,75,,,percent of total billed charges,75% of total billed charges,149.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,239.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,209.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,209.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,299.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.93,299.5,
NAIL ELASTIC,3613944,CDM,278,RC,C1713,HCPCS,Outpatient,,,554.3,332.58,,99.77,18,,,percent of total billed charges,pays at 18% of total charges,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.01,70,,,percent of total billed charges,70% of total billed charges,415.73,75,,,percent of total billed charges,75% of total billed charges,277.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,554.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,388.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,388.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,554.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,554.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.86,554.3,
PATCH TUTOPLAST PERICARDIUM,3613979,CDM,278,RC,V2785,HCPCS,Outpatient,,,427.5,256.5,,355.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,265.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,213.75,50,,,percent of total billed charges,pays at 50% of total billed charges,299.25,70,,,percent of total billed charges,70% of total billed charges,320.63,75,,,percent of total billed charges,75% of total billed charges,293.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,342,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.34,350,,,Fee Schedule,350% of CMS OPPS Rate,266.07,103,,,Fee Schedule,103% of CMS OPPS Rate,427.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,192.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,162.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,299.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,311.63,230,,,Fee Schedule,230% of CMS OPPS Rate,205.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,427.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,265.37,100,,,Fee Schedule,100% of CMS OPPS Rate,66.99,427.5,
CATH HICKMAN,3614003,CDM,272,RC,C1751,HCPCS,Outpatient,,,465,279,,,,,,Other,Not Separately reimbursable,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.5,70,,,percent of total billed charges,70% of total billed charges,348.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,325.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,325.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.87,418.5,
TIBIAL INSERT,3614038,CDM,278,RC,C1776,HCPCS,Outpatient,,,1437.5,862.5,,,,,,Other,Not Separately reimbursable,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.25,70,,,percent of total billed charges,70% of total billed charges,1078.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1150,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1437.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,247.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1006.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,862.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1006.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,690,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1437.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.26,1437.5,
TIBIAL TRAY,3614039,CDM,278,RC,C1776,HCPCS,Outpatient,,,3542.5,2125.5,,,,,,Other,Not Separately reimbursable,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2479.75,70,,,percent of total billed charges,70% of total billed charges,2656.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2834,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3542.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,610.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1594.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2479.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2125.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1346.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2479.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1700.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3542.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,555.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.11,3542.5,
HOODS DISP ORTHO,3614042,CDM,272,RC,,,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.5,50,,,percent of total billed charges,pays at 50% of total billed charges,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
BOWLS MIXING,3614043,CDM,272,RC,,,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,50,,,percent of total billed charges,pays at 50% of total billed charges,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,144,
PLATE,3614061,CDM,278,RC,,,Outpatient,,,1134,680.4,,,,,,Other,Not Separately reimbursable,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567,50,,,percent of total billed charges,pays at 50% of total billed charges,793.8,70,,,percent of total billed charges,70% of total billed charges,850.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,907.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,793.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,680.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,430.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,793.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1134,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.7,1134,
GUIDE WIRE SMOOTH,3614075,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,,,,,Other,Not Separately reimbursable,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,43.65,
HIP COMPLETE,3614089,CDM,278,RC,C1776,HCPCS,Outpatient,,,1891,1134.6,,,,,,Other,Not Separately reimbursable,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1323.7,70,,,percent of total billed charges,70% of total billed charges,1418.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1512.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1891,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,325.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,850.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1323.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1134.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,718.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1323.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1891,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.32,1891,
SCREW CANN 3.0,3614101,CDM,278,RC,C1713,HCPCS,Outpatient,,,323.5,194.1,,,,,,Other,Not Separately reimbursable,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.45,70,,,percent of total billed charges,70% of total billed charges,242.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,258.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,226.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.69,323.5,
DRILL BIT CANN,3614105,CDM,272,RC,,,Outpatient,,,604,362.4,,,,,,Other,Not Separately reimbursable,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302,50,,,percent of total billed charges,pays at 50% of total billed charges,422.8,70,,,percent of total billed charges,70% of total billed charges,453,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,422.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,422.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,543.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.65,543.6,
SCREW 4.0,3614109,CDM,278,RC,C1713,HCPCS,Outpatient,,,709,425.4,,,,,,Other,Not Separately reimbursable,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.3,70,,,percent of total billed charges,70% of total billed charges,531.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,567.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,496.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,425.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,496.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,709,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.1,709,
PLATE 25 MM,3614110,CDM,278,RC,C1713,HCPCS,Outpatient,,,2652.5,1591.5,,,,,,Other,Not Separately reimbursable,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856.75,70,,,percent of total billed charges,70% of total billed charges,1989.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2652.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,457.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1856.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1591.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1007.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1856.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2652.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.65,2652.5,
DRILL BIT DISP,3614111,CDM,272,RC,,,Outpatient,,,530.5,318.3,,,,,,Other,Not Separately reimbursable,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.25,50,,,percent of total billed charges,pays at 50% of total billed charges,371.35,70,,,percent of total billed charges,70% of total billed charges,397.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.13,477.45,
GUIDEWIRE BALL NOSE,3614112,CDM,272,RC,C1769,HCPCS,Outpatient,,,269,161.4,,,,,,Other,Not Separately reimbursable,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.15,242.1,
DRILL BIT DISP,3614113,CDM,272,RC,,,Outpatient,,,291,174.6,,,,,,Other,Not Separately reimbursable,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.5,50,,,percent of total billed charges,pays at 50% of total billed charges,203.7,70,,,percent of total billed charges,70% of total billed charges,218.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,203.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,261.9,
ELECTRODE LOOP DISP,3614114,CDM,272,RC,,,Outpatient,,,109,65.4,,,,,,Other,Not Separately reimbursable,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.5,50,,,percent of total billed charges,pays at 50% of total billed charges,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,98.1,
CYSTO CYLINDER 12 DISP,3614115,CDM,272,RC,,,Outpatient,,,206,123.6,,,,,,Other,Not Separately reimbursable,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103,50,,,percent of total billed charges,pays at 50% of total billed charges,144.2,70,,,percent of total billed charges,70% of total billed charges,154.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,185.4,
BONE MILL,3614116,CDM,272,RC,,,Outpatient,,,436,261.6,,,,,,Other,Not Separately reimbursable,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218,50,,,percent of total billed charges,pays at 50% of total billed charges,305.2,70,,,percent of total billed charges,70% of total billed charges,327,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,348.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,305.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,305.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,392.4,
ENDOTRACH TUBE 2.0-9.0,3614117,CDM,272,RC,,,Outpatient,,,9.5,5.7,,,,,,Other,Not Separately reimbursable,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,8.55,
BONE PRESS,3614118,CDM,272,RC,,,Outpatient,,,520,312,,,,,,Other,Not Separately reimbursable,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260,50,,,percent of total billed charges,pays at 50% of total billed charges,364,70,,,percent of total billed charges,70% of total billed charges,390,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,468,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,468,
TRACH SHILEY,3614153,CDM,272,RC,,,Outpatient,,,222.5,133.5,,,,,,Other,Not Separately reimbursable,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,50,,,percent of total billed charges,pays at 50% of total billed charges,155.75,70,,,percent of total billed charges,70% of total billed charges,166.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.87,200.25,
SET INITIAL TRACHEAL CANNULA SHORT TERM,3614161,CDM,272,RC,,,Outpatient,,,365,219,,,,,,Other,Not Separately reimbursable,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.5,50,,,percent of total billed charges,pays at 50% of total billed charges,255.5,70,,,percent of total billed charges,70% of total billed charges,273.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.2,328.5,
DEVICE STOMA MEASURE DISP,3614162,CDM,272,RC,,,Outpatient,,,42,25.2,,,,,,Other,Not Separately reimbursable,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,50,,,percent of total billed charges,pays at 50% of total billed charges,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,37.8,
VALVE ONE-WAY SPEAKING,3614163,CDM,274,RC,L8501,HCPCS,Outpatient,,,168,100.8,,488.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,138,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,84,50,,,percent of total billed charges,pays at 50% of total billed charges,117.6,70,,,percent of total billed charges,70% of total billed charges,126,75,,,percent of total billed charges,75% of total billed charges,248.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,483,350,,,Fee Schedule,350% of CMS OPPS Rate,140.76,102,,,Fee Schedule,102% of CMS OPPS Rate,168,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,75.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,138,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,63.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,168,230,,,Fee Schedule,230% of CMS OPPS Rate,80.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,138,100,,,Fee Schedule,100% of CMS OPPS Rate,168,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,138,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,26.33,488.52,
GUIDEWIRE ORTHO,3614215,CDM,272,RC,C1769,HCPCS,Outpatient,,,170,102,,,,,,Other,Not Separately reimbursable,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,153,
GUIDE ROD BALL TIP,3614217,CDM,272,RC,C1769,HCPCS,Outpatient,,,421.2,252.72,,,,,,Other,Not Separately reimbursable,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.9,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,336.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,294.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,252.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,294.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,379.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,379.08,
PINS MBT,3614219,CDM,278,RC,C1713,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
TUBE SUCTION,3614254,CDM,272,RC,,,Outpatient,,,29.5,17.7,,,,,,Other,Not Separately reimbursable,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,26.55,
PASTE BONE HEMOSTATIC,3614367,CDM,278,RC,,,Outpatient,,,3379,2027.4,,,,,,Other,Not Separately reimbursable,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1689.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2365.3,70,,,percent of total billed charges,70% of total billed charges,2534.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2703.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3379,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1520.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2365.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2027.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1284.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2365.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1621.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3379,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,529.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.49,3379,
SPACER BONE,3614368,CDM,278,RC,,,Outpatient,,,600,360,,,,,,Other,Not Separately reimbursable,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,50,,,percent of total billed charges,pays at 50% of total billed charges,420,70,,,percent of total billed charges,70% of total billed charges,450,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.02,600,
FILTER GREENFIELD FEMORAL,3614369,CDM,278,RC,,,Outpatient,,,2500,1500,,,,,,Other,Not Separately reimbursable,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250,50,,,percent of total billed charges,pays at 50% of total billed charges,1750,70,,,percent of total billed charges,70% of total billed charges,1875,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1750,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1500,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,950,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1750,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1200,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.75,2500,
SPACER BONE,3614370,CDM,278,RC,,,Outpatient,,,1614,968.4,,,,,,Other,Not Separately reimbursable,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807,50,,,percent of total billed charges,pays at 50% of total billed charges,1129.8,70,,,percent of total billed charges,70% of total billed charges,1210.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1614,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1129.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,968.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,613.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1129.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1614,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.91,1614,
SPACER BONE,3614371,CDM,278,RC,,,Outpatient,,,4222,2533.2,,,,,,Other,Not Separately reimbursable,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2111,50,,,percent of total billed charges,pays at 50% of total billed charges,2955.4,70,,,percent of total billed charges,70% of total billed charges,3166.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4222,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1899.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2955.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2533.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1604.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2955.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2026.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4222,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.59,4222,
NAIL HINDFOOT FUSION,3614375,CDM,278,RC,C1713,HCPCS,Outpatient,,,5233,3139.8,,,,,,Other,Not Separately reimbursable,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3663.1,70,,,percent of total billed charges,70% of total billed charges,3924.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,901.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2354.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3663.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3139.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1988.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3663.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2511.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5233,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.01,5233,
NAIL HINDFOOT,3614376,CDM,278,RC,C1713,HCPCS,Outpatient,,,2391.5,1434.9,,,,,,Other,Not Separately reimbursable,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1674.05,70,,,percent of total billed charges,70% of total billed charges,1793.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1913.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2391.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,412.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1076.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1674.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1434.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,908.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1674.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2391.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.75,2391.5,
NAIL HINDFOOT,3614378,CDM,278,RC,C1713,HCPCS,Outpatient,,,1447,868.2,,,,,,Other,Not Separately reimbursable,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.9,70,,,percent of total billed charges,70% of total billed charges,1085.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1447,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,249.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1012.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,868.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1012.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.74,1447,
NAIL PHANTOM,3614380,CDM,278,RC,C1713,HCPCS,Outpatient,,,10465,6279,,,,,,Other,Not Separately reimbursable,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7325.5,70,,,percent of total billed charges,70% of total billed charges,7848.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10465,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1803.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4709.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7325.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6279,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3976.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7325.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5023.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10465,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1639.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.87,10465,
PAIN PUMP INFUS,3614383,CDM,272,RC,,,Outpatient,,,717,430.2,,,,,,Other,Not Separately reimbursable,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.5,50,,,percent of total billed charges,pays at 50% of total billed charges,501.9,70,,,percent of total billed charges,70% of total billed charges,537.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,645.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.35,645.3,
NAIL PHANTOM,3614385,CDM,278,RC,C1713,HCPCS,Outpatient,,,501,300.6,,,,,,Other,Not Separately reimbursable,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.7,70,,,percent of total billed charges,70% of total billed charges,375.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,400.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,350.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,350.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.51,501,
DURA REPAIR PATCH,3614397,CDM,278,RC,C1762,HCPCS,Outpatient,,,2615.5,1569.3,,,,,,Other,Not Separately reimbursable,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.85,70,,,percent of total billed charges,70% of total billed charges,1961.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2092.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2615.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,450.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1830.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1569.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,993.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1830.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1255.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2615.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.85,2615.5,
HUMERAL HEAD,3614400,CDM,278,RC,C1776,HCPCS,Outpatient,,,2330,1398,,,,,,Other,Not Separately reimbursable,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1631,70,,,percent of total billed charges,70% of total billed charges,1747.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1864,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2330,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,401.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1048.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1631,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1398,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,885.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1631,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1118.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.11,2330,
PENILE RESERVOIR,3614406,CDM,278,RC,C1813,HCPCS,Outpatient,,,3059,1835.4,,,,,,Other,Not Separately reimbursable,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2141.3,70,,,percent of total billed charges,70% of total billed charges,2294.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2447.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3059,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,527.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1376.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2141.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1835.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1162.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2141.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1468.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3059,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,479.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.35,3059,
SPACER VERTEBRAE,3614407,CDM,278,RC,C1821,HCPCS,Outpatient,,,7520,4512,,,,,,Other,Not Separately reimbursable,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5264,70,,,percent of total billed charges,70% of total billed charges,5640,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7520,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1295.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3384,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4512,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2857.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5264,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3609.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1178.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1178.38,7520,
DEVICE MICRODEBRIDER DISP,3614409,CDM,272,RC,,,Outpatient,,,668,400.8,,,,,,Other,Not Separately reimbursable,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334,50,,,percent of total billed charges,pays at 50% of total billed charges,467.6,70,,,percent of total billed charges,70% of total billed charges,501,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,534.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,467.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,467.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,601.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.68,601.2,
PROBE TAC S VULCAN,3614411,CDM,272,RC,,,Outpatient,,,941,564.6,,,,,,Other,Not Separately reimbursable,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.5,50,,,percent of total billed charges,pays at 50% of total billed charges,658.7,70,,,percent of total billed charges,70% of total billed charges,705.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,658.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,564.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,658.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,846.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.45,846.9,
PROBE TAC S VULCAN,3614412,CDM,272,RC,,,Outpatient,,,941,564.6,,,,,,Other,Not Separately reimbursable,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.5,50,,,percent of total billed charges,pays at 50% of total billed charges,658.7,70,,,percent of total billed charges,70% of total billed charges,705.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,752.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,658.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,564.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,658.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,846.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.45,846.9,
PLATE T LCP,3614413,CDM,278,RC,C1713,HCPCS,Outpatient,,,600.5,360.3,,,,,,Other,Not Separately reimbursable,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.35,70,,,percent of total billed charges,70% of total billed charges,450.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,480.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,420.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,420.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,600.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,600.5,
PLATE  ANT CERVICAL,3614417,CDM,278,RC,C1713,HCPCS,Outpatient,,,2809,1685.4,,,,,,Other,Not Separately reimbursable,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1966.3,70,,,percent of total billed charges,70% of total billed charges,2106.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2809,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,483.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1264.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1966.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1685.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1067.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1966.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1348.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2809,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.17,2809,
PROBE PIERCER,3614418,CDM,272,RC,,,Outpatient,,,1040,624,,,,,,Other,Not Separately reimbursable,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,936,
PLATE SPINAL HORIZON CD,3614423,CDM,278,RC,C1713,HCPCS,Outpatient,,,9847.04,5908.22,,,,,,Other,Not Separately reimbursable,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6892.93,70,,,percent of total billed charges,70% of total billed charges,7385.28,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7877.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9847.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1696.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4431.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6892.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5908.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3741.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6892.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4726.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9847.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1543.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1543.03,9847.04,
APPLIER MULTICLIP,3614425,CDM,272,RC,,,Outpatient,,,380,228,,,,,,Other,Not Separately reimbursable,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190,50,,,percent of total billed charges,pays at 50% of total billed charges,266,70,,,percent of total billed charges,70% of total billed charges,285,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,266,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,266,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.55,342,
PROBE SCRAPER,3614428,CDM,272,RC,,,Outpatient,,,1040,624,,,,,,Other,Not Separately reimbursable,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,936,
DRILL BIT,3614438,CDM,272,RC,,,Outpatient,,,84,50.4,,,,,,Other,Not Separately reimbursable,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,50,,,percent of total billed charges,pays at 50% of total billed charges,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,75.6,
SCREW LAG,3614440,CDM,278,RC,C1713,HCPCS,Outpatient,,,763.5,458.1,,,,,,Other,Not Separately reimbursable,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.45,70,,,percent of total billed charges,70% of total billed charges,572.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,610.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,534.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,534.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,763.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.64,763.5,
PLATE FIBULA,3614441,CDM,278,RC,C1713,HCPCS,Outpatient,,,1022,613.2,,,,,,Other,Not Separately reimbursable,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.4,70,,,percent of total billed charges,70% of total billed charges,766.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,817.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1022,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,715.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,613.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,388.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,715.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1022,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.15,1022,
KIT SCREW COMBO LAG CMPRSSN,3614442,CDM,278,RC,C1713,HCPCS,Outpatient,,,960.7,576.42,,,,,,Other,Not Separately reimbursable,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.49,70,,,percent of total billed charges,70% of total billed charges,720.53,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,768.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,165.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,672.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,576.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,672.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,960.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.54,960.7,
AUGUMENTATION HUMERAL,3614443,CDM,278,RC,C1776,HCPCS,Outpatient,,,975,585,,,,,,Other,Not Separately reimbursable,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,167.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
GUIDE PIN,3614447,CDM,272,RC,C1769,HCPCS,Outpatient,,,368,220.8,,,,,,Other,Not Separately reimbursable,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,331.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.67,331.2,
FEMORAL STEM,3614448,CDM,278,RC,C1776,HCPCS,Outpatient,,,9686.5,5811.9,,,,,,Other,Not Separately reimbursable,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6780.55,70,,,percent of total billed charges,70% of total billed charges,7264.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7749.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9686.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1668.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4358.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6780.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5811.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3680.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6780.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4649.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9686.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1517.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1517.87,9686.5,
KIT NEUROMONITOR,3614454,CDM,272,RC,,,Outpatient,,,776.5,465.9,,,,,,Other,Not Separately reimbursable,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.25,50,,,percent of total billed charges,pays at 50% of total billed charges,543.55,70,,,percent of total billed charges,70% of total billed charges,582.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,621.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,543.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,465.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,543.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.68,698.85,
ACETABULAR CUP,3614455,CDM,278,RC,C1776,HCPCS,Outpatient,,,1413,847.8,,,,,,Other,Not Separately reimbursable,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.1,70,,,percent of total billed charges,70% of total billed charges,1059.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1413,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,243.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,989.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,847.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,536.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,989.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1413,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.42,1413,
HUMERAL TRAY,3614456,CDM,278,RC,C1776,HCPCS,Outpatient,,,1820,1092,,,,,,Other,Not Separately reimbursable,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1274,70,,,percent of total billed charges,70% of total billed charges,1365,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,313.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1274,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,691.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1274,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1820,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.19,1820,
HUMERAL BEARING,3614457,CDM,278,RC,C1776,HCPCS,Outpatient,,,780,468,,,,,,Other,Not Separately reimbursable,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
PAD BOVIE NEONATAL,3614461,CDM,272,RC,,,Outpatient,,,37,22.2,,,,,,Other,Not Separately reimbursable,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,50,,,percent of total billed charges,pays at 50% of total billed charges,25.9,70,,,percent of total billed charges,70% of total billed charges,27.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.8,33.3,
IMPLANT BIPOLAR HIP,3614464,CDM,278,RC,C1776,HCPCS,Outpatient,,,150,90,,,,,,Other,Not Separately reimbursable,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
PVC SELF-THREADING MONKA,3614467,CDM,272,RC,,,Outpatient,,,312,187.2,,,,,,Other,Not Separately reimbursable,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,50,,,percent of total billed charges,pays at 50% of total billed charges,218.4,70,,,percent of total billed charges,70% of total billed charges,234,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.89,280.8,
PUNCTUM DIL/PLUG INSERTER,3614468,CDM,272,RC,,,Outpatient,,,33.5,20.1,,,,,,Other,Not Separately reimbursable,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,50,,,percent of total billed charges,pays at 50% of total billed charges,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,30.15,
BLADE SAW,3614475,CDM,272,RC,,,Outpatient,,,127,76.2,,,,,,Other,Not Separately reimbursable,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,50,,,percent of total billed charges,pays at 50% of total billed charges,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,114.3,
CATH LUMBAR EDM,3614476,CDM,272,RC,,,Outpatient,,,325.5,195.3,,,,,,Other,Not Separately reimbursable,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.75,50,,,percent of total billed charges,pays at 50% of total billed charges,227.85,70,,,percent of total billed charges,70% of total billed charges,244.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,227.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,227.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.01,292.95,
PLATE TIBIAL BASE,3614486,CDM,278,RC,C1776,HCPCS,Outpatient,,,3919.5,2351.7,,,,,,Other,Not Separately reimbursable,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2743.65,70,,,percent of total billed charges,70% of total billed charges,2939.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3135.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3919.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,675.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2743.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2351.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1489.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2743.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1881.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3919.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,614.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.19,3919.5,
BLADE SAW,3614488,CDM,272,RC,,,Outpatient,,,158.5,95.1,,,,,,Other,Not Separately reimbursable,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.25,50,,,percent of total billed charges,pays at 50% of total billed charges,110.95,70,,,percent of total billed charges,70% of total billed charges,118.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,142.65,
BAG DRAIN BECKER EDMS,3614501,CDM,272,RC,,,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,74.7,
HIP SYS,3614504,CDM,278,RC,C1776,HCPCS,Outpatient,,,7716.5,4629.9,,,,,,Other,Not Separately reimbursable,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5401.55,70,,,percent of total billed charges,70% of total billed charges,5787.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7716.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1329.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3472.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5401.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4629.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2932.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5401.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3703.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7716.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.18,7716.5,
FEMORAL COMPONENT,3614510,CDM,278,RC,C1776,HCPCS,Outpatient,,,3433.5,2060.1,,,,,,Other,Not Separately reimbursable,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2403.45,70,,,percent of total billed charges,70% of total billed charges,2575.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2746.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3433.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,591.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1545.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2403.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2060.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1304.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2403.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1648.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3433.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,538.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.03,3433.5,
COMPONENT FEMORAL SEGMENT,3614512,CDM,278,RC,C1776,HCPCS,Outpatient,,,10882.87,6529.72,,,,,,Other,Not Separately reimbursable,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7618.01,70,,,percent of total billed charges,70% of total billed charges,8162.15,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8706.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10882.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1875.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4897.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7618.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6529.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4135.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7618.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10882.87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1705.35,10882.87,
CONNECTOR TRANSVERSE ROD,3614517,CDM,278,RC,,,Outpatient,,,200.5,120.3,,,,,,Other,Not Separately reimbursable,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.25,50,,,percent of total billed charges,pays at 50% of total billed charges,140.35,70,,,percent of total billed charges,70% of total billed charges,150.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,200.5,
COMPONENT FEMORAL PROXIMAL,3614518,CDM,278,RC,C1776,HCPCS,Outpatient,,,10831.52,6498.91,,,,,,Other,Not Separately reimbursable,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7582.06,70,,,percent of total billed charges,70% of total billed charges,8123.64,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8665.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10831.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1866.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4874.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7582.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6498.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4115.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7582.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5199.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10831.52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1697.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1697.3,10831.52,
FEMORAL HEAD,3614524,CDM,278,RC,C1776,HCPCS,Outpatient,,,4253.15,2551.89,,,,,,Other,Not Separately reimbursable,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2977.21,70,,,percent of total billed charges,70% of total billed charges,3189.86,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3402.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4253.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,732.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1913.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2977.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2551.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1616.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2977.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2041.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4253.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.47,4253.15,
BOLT FIXATION,3614528,CDM,278,RC,C1776,HCPCS,Outpatient,,,579.2,347.52,,,,,,Other,Not Separately reimbursable,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.44,70,,,percent of total billed charges,70% of total billed charges,434.4,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,463.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,99.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,405.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,347.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,405.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,579.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.76,579.2,
PAT & PLANER BLD,3614539,CDM,272,RC,,,Outpatient,,,286.5,171.9,,,,,,Other,Not Separately reimbursable,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.25,50,,,percent of total billed charges,pays at 50% of total billed charges,200.55,70,,,percent of total billed charges,70% of total billed charges,214.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,229.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.89,257.85,
DRILL BIT 4.5,3614540,CDM,272,RC,,,Outpatient,,,171,102.6,,,,,,Other,Not Separately reimbursable,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.5,50,,,percent of total billed charges,pays at 50% of total billed charges,119.7,70,,,percent of total billed charges,70% of total billed charges,128.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.8,153.9,
DRILL BIT 3.2,3614541,CDM,272,RC,,,Outpatient,,,190,114,,,,,,Other,Not Separately reimbursable,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95,50,,,percent of total billed charges,pays at 50% of total billed charges,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,171,
CATH PASSER,3614542,CDM,272,RC,,,Outpatient,,,765,459,,,,,,Other,Not Separately reimbursable,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.5,50,,,percent of total billed charges,pays at 50% of total billed charges,535.5,70,,,percent of total billed charges,70% of total billed charges,573.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,535.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,535.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,688.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.88,688.5,
CATH PASSER,3614544,CDM,272,RC,,,Outpatient,,,271,162.6,,,,,,Other,Not Separately reimbursable,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.5,50,,,percent of total billed charges,pays at 50% of total billed charges,189.7,70,,,percent of total billed charges,70% of total billed charges,203.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,189.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.47,243.9,
DEVICE TISSUE SEALER,3614545,CDM,272,RC,,,Outpatient,,,1515,909,,,,,,Other,Not Separately reimbursable,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1060.5,70,,,percent of total billed charges,70% of total billed charges,1136.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1158.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1060.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,909,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,575.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1060.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1363.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.4,1363.5,
DEVICE TISSUE SEALER MAX,3614546,CDM,272,RC,,,Outpatient,,,444,266.4,,,,,,Other,Not Separately reimbursable,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222,50,,,percent of total billed charges,pays at 50% of total billed charges,310.8,70,,,percent of total billed charges,70% of total billed charges,333,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,310.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,310.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,399.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.57,399.6,
ADAPTER LCKG TITANIUM,3614550,CDM,272,RC,,,Outpatient,,,330,198,,,,,,Other,Not Separately reimbursable,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165,50,,,percent of total billed charges,pays at 50% of total billed charges,231,70,,,percent of total billed charges,70% of total billed charges,247.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.71,297,
ABLATOR VULCAN S PROBE,3614553,CDM,272,RC,,,Outpatient,,,519,311.4,,,,,,Other,Not Separately reimbursable,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.5,50,,,percent of total billed charges,pays at 50% of total billed charges,363.3,70,,,percent of total billed charges,70% of total billed charges,389.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,415.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,363.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,363.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,467.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.33,467.1,
EXTRACTION PROBE,3614554,CDM,272,RC,,,Outpatient,,,1040,624,,,,,,Other,Not Separately reimbursable,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,936,
SYSTEM IRRGTD RF SURGICAL ABLATION & PEN,3614557,CDM,272,RC,,,Outpatient,,,3633.5,2180.1,,,,,,Other,Not Separately reimbursable,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.75,50,,,percent of total billed charges,pays at 50% of total billed charges,2543.45,70,,,percent of total billed charges,70% of total billed charges,2725.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2906.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2779.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1635.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2543.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2180.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1380.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2543.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1744.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3270.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.37,3270.15,
SHUNT SENSOR,3614559,CDM,272,RC,,,Outpatient,,,203.5,122.1,,36.63,18,,,percent of total billed charges,pays at 18% of total charges,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.75,50,,,percent of total billed charges,pays at 50% of total billed charges,142.45,70,,,percent of total billed charges,70% of total billed charges,152.63,75,,,percent of total billed charges,75% of total billed charges,101.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.89,203.5,
STAPLE SKIN PRECISE VISTA,3614560,CDM,272,RC,,,Outpatient,,,76,45.6,,13.68,18,,,percent of total billed charges,pays at 18% of total charges,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,50,,,percent of total billed charges,pays at 50% of total billed charges,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,76,
BLADE PLANER,3614574,CDM,272,RC,,,Outpatient,,,398,238.8,,71.64,18,,,percent of total billed charges,pays at 18% of total charges,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199,50,,,percent of total billed charges,pays at 50% of total billed charges,278.6,70,,,percent of total billed charges,70% of total billed charges,298.5,75,,,percent of total billed charges,75% of total billed charges,199,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,398,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,358.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.37,398,
PAT & PLANER LG,3614580,CDM,272,RC,,,Outpatient,,,260.5,156.3,,46.89,18,,,percent of total billed charges,pays at 18% of total charges,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.25,50,,,percent of total billed charges,pays at 50% of total billed charges,182.35,70,,,percent of total billed charges,70% of total billed charges,195.38,75,,,percent of total billed charges,75% of total billed charges,130.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,260.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,234.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.82,260.5,
SCREW BIO-CORK,3614582,CDM,278,RC,C1713,HCPCS,Outpatient,,,510.5,306.3,,91.89,18,,,percent of total billed charges,pays at 18% of total charges,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.35,70,,,percent of total billed charges,70% of total billed charges,382.88,75,,,percent of total billed charges,75% of total billed charges,255.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,510.5,
PLATE CONDYLAR LGE,3614588,CDM,278,RC,C1713,HCPCS,Outpatient,,,2475,1485,,445.5,18,,,percent of total billed charges,pays at 18% of total charges,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1732.5,70,,,percent of total billed charges,70% of total billed charges,1856.25,75,,,percent of total billed charges,75% of total billed charges,1237.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1485,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2475,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,426.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1732.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1485,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,940.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1732.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2475,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2475,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.83,2475,
PLATE TIBIAL BASE,3614595,CDM,278,RC,C1776,HCPCS,Outpatient,,,5931.9,3559.14,,1067.74,18,,,percent of total billed charges,pays at 18% of total charges,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1067.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4152.33,70,,,percent of total billed charges,70% of total billed charges,4448.93,75,,,percent of total billed charges,75% of total billed charges,2965.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4745.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3559.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5931.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1022.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2669.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4152.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3559.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2254.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4152.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2847.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5931.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5931.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,929.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.53,5931.9,
TISSUE BUTTON,3614600,CDM,278,RC,C1713,HCPCS,Outpatient,,,239.5,143.7,,43.11,18,,,percent of total billed charges,pays at 18% of total charges,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.65,70,,,percent of total billed charges,70% of total billed charges,179.63,75,,,percent of total billed charges,75% of total billed charges,119.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,167.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.53,239.5,
COLLAGEN POWDER 1 GRAM,3614630,CDM,272,RC,,,Outpatient,,,475,285,,85.5,18,,,percent of total billed charges,pays at 18% of total charges,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.5,50,,,percent of total billed charges,pays at 50% of total billed charges,332.5,70,,,percent of total billed charges,70% of total billed charges,356.25,75,,,percent of total billed charges,75% of total billed charges,237.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,363.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,285,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,332.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,475,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,427.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,475,
SCREW 4.0,3614636,CDM,278,RC,C1713,HCPCS,Outpatient,,,507,304.2,,91.26,18,,,percent of total billed charges,pays at 18% of total charges,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.9,70,,,percent of total billed charges,70% of total billed charges,380.25,75,,,percent of total billed charges,75% of total billed charges,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,507,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,507,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.45,507,
PLATE 12 DEG ANG,3614638,CDM,278,RC,,,Outpatient,,,2128.5,1277.1,,383.13,18,,,percent of total billed charges,pays at 18% of total charges,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1064.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1489.95,70,,,percent of total billed charges,70% of total billed charges,1596.38,75,,,percent of total billed charges,75% of total billed charges,1064.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1702.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1277.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2128.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1489.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1277.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,808.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1489.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2128.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2128.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.54,2128.5,
NUT DIAMOND,3614639,CDM,278,RC,C1713,HCPCS,Outpatient,,,131.5,78.9,,23.67,18,,,percent of total billed charges,pays at 18% of total charges,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,65.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,131.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.61,131.5,
COLLAGEN POWDER 5 GRAM,3614640,CDM,272,RC,,,Outpatient,,,1755,1053,,315.9,18,,,percent of total billed charges,pays at 18% of total charges,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,877.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1228.5,70,,,percent of total billed charges,70% of total billed charges,1316.25,75,,,percent of total billed charges,75% of total billed charges,877.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1053,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1342.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1228.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1053,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1228.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,842.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1755,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1579.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.01,1755,
FEMORAL COLLAR,3614641,CDM,278,RC,C1776,HCPCS,Outpatient,,,7898,4738.8,,1421.64,18,,,percent of total billed charges,pays at 18% of total charges,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1421.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5528.6,70,,,percent of total billed charges,70% of total billed charges,5923.5,75,,,percent of total billed charges,75% of total billed charges,3949,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6318.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4738.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7898,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1360.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3554.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5528.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4738.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3001.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5528.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3791.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7898,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7898,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1237.62,7898,
VALVE CHPV MICRO,3614647,CDM,278,RC,,,Outpatient,,,5240.5,3144.3,,943.29,18,,,percent of total billed charges,pays at 18% of total charges,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,943.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2620.25,50,,,percent of total billed charges,pays at 50% of total billed charges,3668.35,70,,,percent of total billed charges,70% of total billed charges,3930.38,75,,,percent of total billed charges,75% of total billed charges,2620.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5240.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2358.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3668.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1991.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3668.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2515.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,821.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,821.19,5240.5,
FEMORAL KNEE W EPHIPHYSIS,3614649,CDM,278,RC,C1776,HCPCS,Outpatient,,,13250.25,7950.15,,2385.05,18,,,percent of total billed charges,pays at 18% of total charges,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2385.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9275.18,70,,,percent of total billed charges,70% of total billed charges,9937.69,75,,,percent of total billed charges,75% of total billed charges,6625.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10600.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7950.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13250.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2283.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5962.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9275.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7950.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5035.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9275.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6360.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13250.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13250.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2076.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2076.31,13250.25,
TIBIAL INSERT HINGED,3614650,CDM,278,RC,C1776,HCPCS,Outpatient,,,8824,5294.4,,1588.32,18,,,percent of total billed charges,pays at 18% of total charges,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1588.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6176.8,70,,,percent of total billed charges,70% of total billed charges,6618,75,,,percent of total billed charges,75% of total billed charges,4412,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7059.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5294.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8824,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1520.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3970.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6176.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5294.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3353.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6176.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4235.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8824,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8824,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1382.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1382.72,8824,
MATRIX WD DERMACELL PER SQ CM,3614651,CDM,636,RC,Q4122,HCPCS,Outpatient,,,68,40.8,,12.24,18,,,percent of total billed charges,pays at 18% of total charges,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34,50,,,percent of total billed charges,pays at 50% of total billed charges,47.6,70,,,percent of total billed charges,70% of total billed charges,51,75,,,percent of total billed charges,75% of total billed charges,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,68,
PLATE LCKG META VOLAR RADIUS,3614654,CDM,278,RC,C1713,HCPCS,Outpatient,,,2169,1301.4,,390.42,18,,,percent of total billed charges,pays at 18% of total charges,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,390.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.3,70,,,percent of total billed charges,70% of total billed charges,1626.75,75,,,percent of total billed charges,75% of total billed charges,1084.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1735.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1301.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2169,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,373.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,976.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1518.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1301.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,824.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1518.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.88,2169,
SLEEVE,3614656,CDM,272,RC,,,Outpatient,,,345.5,207.3,,62.19,18,,,percent of total billed charges,pays at 18% of total charges,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.75,50,,,percent of total billed charges,pays at 50% of total billed charges,241.85,70,,,percent of total billed charges,70% of total billed charges,259.13,75,,,percent of total billed charges,75% of total billed charges,172.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,276.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,241.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,241.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,345.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,310.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.14,345.5,
ACETABULAR LINER,3614661,CDM,278,RC,C1776,HCPCS,Outpatient,,,1867,1120.2,,336.06,18,,,percent of total billed charges,pays at 18% of total charges,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1306.9,70,,,percent of total billed charges,70% of total billed charges,1400.25,75,,,percent of total billed charges,75% of total billed charges,933.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1493.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1867,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,321.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1306.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1120.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,709.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1306.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1867,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1867,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.56,1867,
BLADE CUTTING ILLUMINATED,3614666,CDM,272,RC,,,Outpatient,,,422.5,253.5,,76.05,18,,,percent of total billed charges,pays at 18% of total charges,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.25,50,,,percent of total billed charges,pays at 50% of total billed charges,295.75,70,,,percent of total billed charges,70% of total billed charges,316.88,75,,,percent of total billed charges,75% of total billed charges,211.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,295.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,295.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,422.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,422.5,
MATRIX WD DERMACELL WASTE PER SQ CM,3614667,CDM,278,RC,Q4122,HCPCS,Outpatient,,,68,40.8,,12.24,18,,,percent of total billed charges,pays at 18% of total charges,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34,50,,,percent of total billed charges,pays at 50% of total billed charges,47.6,70,,,percent of total billed charges,70% of total billed charges,51,75,,,percent of total billed charges,75% of total billed charges,34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.66,68,
MATRIX WD DERMACELL WASTE PER SQ CM,3614668,CDM,278,RC,Q4122,HCPCS,Outpatient,,,117,70.2,,21.06,18,,,percent of total billed charges,pays at 18% of total charges,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,50,,,percent of total billed charges,pays at 50% of total billed charges,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,117,
SUTURE LASSO,3614669,CDM,272,RC,,,Outpatient,,,479,287.4,,86.22,18,,,percent of total billed charges,pays at 18% of total charges,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.5,50,,,percent of total billed charges,pays at 50% of total billed charges,335.3,70,,,percent of total billed charges,70% of total billed charges,359.25,75,,,percent of total billed charges,75% of total billed charges,239.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,383.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,366.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,479,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,431.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.06,479,
ACETABULAR LINER,3614671,CDM,278,RC,C1776,HCPCS,Outpatient,,,2075,1245,,373.5,18,,,percent of total billed charges,pays at 18% of total charges,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1452.5,70,,,percent of total billed charges,70% of total billed charges,1556.25,75,,,percent of total billed charges,75% of total billed charges,1037.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1660,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1245,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2075,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,357.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,933.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1452.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1245,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,788.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1452.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,996,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2075,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2075,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.15,2075,
SYS IMPLANT TENDON REPAIR,3614672,CDM,278,RC,C1763,HCPCS,Outpatient,,,3705,2223,,666.9,18,,,percent of total billed charges,pays at 18% of total charges,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2593.5,70,,,percent of total billed charges,70% of total billed charges,2778.75,75,,,percent of total billed charges,75% of total billed charges,1852.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2223,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3705,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,638.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1667.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2593.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2223,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1407.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2593.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1778.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3705,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3705,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,580.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.57,3705,
SCREW SCHANZ,3614673,CDM,278,RC,C1713,HCPCS,Outpatient,,,138.5,83.1,,24.93,18,,,percent of total billed charges,pays at 18% of total charges,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.95,70,,,percent of total billed charges,70% of total billed charges,103.88,75,,,percent of total billed charges,75% of total billed charges,69.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,138.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,138.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,138.5,
SCREW CANN 7.3,3614674,CDM,278,RC,C1713,HCPCS,Outpatient,,,382,229.2,,68.76,18,,,percent of total billed charges,pays at 18% of total charges,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.4,70,,,percent of total billed charges,70% of total billed charges,286.5,75,,,percent of total billed charges,75% of total billed charges,191,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,305.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,267.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,267.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,382,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.86,382,
TIBIAL WEDGE,3614682,CDM,278,RC,C1776,HCPCS,Outpatient,,,3252,1951.2,,585.36,18,,,percent of total billed charges,pays at 18% of total charges,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,585.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2276.4,70,,,percent of total billed charges,70% of total billed charges,2439,75,,,percent of total billed charges,75% of total billed charges,1626,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2601.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1951.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3252,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,560.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1463.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2276.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1951.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2276.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.59,3252,
PLATE RADIUS DISTAL,3614690,CDM,278,RC,C1713,HCPCS,Outpatient,,,1305,783,,234.9,18,,,percent of total billed charges,pays at 18% of total charges,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.5,70,,,percent of total billed charges,70% of total billed charges,978.75,75,,,percent of total billed charges,75% of total billed charges,652.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1044,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,783,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1305,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,224.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,913.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,783,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,495.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,913.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1305,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1305,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.49,1305,
AUGMENTATION TIBIAL,3614691,CDM,278,RC,C1776,HCPCS,Outpatient,,,1981.2,1188.72,,356.62,18,,,percent of total billed charges,pays at 18% of total charges,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386.84,70,,,percent of total billed charges,70% of total billed charges,1485.9,75,,,percent of total billed charges,75% of total billed charges,990.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1584.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1188.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1981.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,891.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1386.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1188.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,752.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1386.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1981.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1981.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.45,1981.2,
TIBIAL BASEPLATE,3614692,CDM,278,RC,C1776,HCPCS,Outpatient,,,9176.65,5505.99,,1651.8,18,,,percent of total billed charges,pays at 18% of total charges,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1651.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6423.66,70,,,percent of total billed charges,70% of total billed charges,6882.49,75,,,percent of total billed charges,75% of total billed charges,4588.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7341.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5505.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9176.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1581.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4129.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6423.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5505.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3487.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6423.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4404.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9176.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9176.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1437.98,9176.65,
RESTORE SOFT TISSUE IMPLANT,3614694,CDM,278,RC,C1762,HCPCS,Outpatient,,,4460.5,2676.3,,802.89,18,,,percent of total billed charges,pays at 18% of total charges,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,802.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3122.35,70,,,percent of total billed charges,70% of total billed charges,3345.38,75,,,percent of total billed charges,75% of total billed charges,2230.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3568.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2676.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4460.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,768.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2007.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3122.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2676.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1694.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3122.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2141.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4460.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4460.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,698.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,698.96,4460.5,
RESERVOIR SALMON-RICKHAM,3614697,CDM,278,RC,C1889,HCPCS,Outpatient,,,592,355.2,,106.56,18,,,percent of total billed charges,pays at 18% of total charges,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.4,70,,,percent of total billed charges,70% of total billed charges,444,75,,,percent of total billed charges,75% of total billed charges,296,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,473.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,414.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,414.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,592,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,592,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.77,592,
FEMORAL HEAD,3614701,CDM,278,RC,C1776,HCPCS,Outpatient,,,2869.5,1721.7,,516.51,18,,,percent of total billed charges,pays at 18% of total charges,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,516.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2008.65,70,,,percent of total billed charges,70% of total billed charges,2152.13,75,,,percent of total billed charges,75% of total billed charges,1434.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2295.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1721.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2869.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,494.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2008.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1721.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1090.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2008.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1377.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2869.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2869.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.65,2869.5,
GRAFT MARKER,3614703,CDM,272,RC,,,Outpatient,,,27.64,16.58,,4.98,18,,,percent of total billed charges,pays at 18% of total charges,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.82,50,,,percent of total billed charges,pays at 50% of total billed charges,19.35,70,,,percent of total billed charges,70% of total billed charges,20.73,75,,,percent of total billed charges,75% of total billed charges,13.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.33,27.64,
ALLODERM,3614704,CDM,278,RC,C1763,HCPCS,Outpatient,,,819,491.4,,147.42,18,,,percent of total billed charges,pays at 18% of total charges,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.3,70,,,percent of total billed charges,70% of total billed charges,614.25,75,,,percent of total billed charges,75% of total billed charges,409.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,655.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,819,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,819,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,819,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.34,819,
ALLODERM,3614705,CDM,278,RC,C1763,HCPCS,Outpatient,,,1080.5,648.3,,194.49,18,,,percent of total billed charges,pays at 18% of total charges,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.35,70,,,percent of total billed charges,70% of total billed charges,810.38,75,,,percent of total billed charges,75% of total billed charges,540.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,864.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,648.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1080.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,186.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,756.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,648.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,756.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1080.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1080.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.31,1080.5,
DRSG CHITOSAN SPONGE 5X5CM,3614706,CDM,272,RC,,,Outpatient,,,427.5,256.5,,76.95,18,,,percent of total billed charges,pays at 18% of total charges,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.75,50,,,percent of total billed charges,pays at 50% of total billed charges,299.25,70,,,percent of total billed charges,70% of total billed charges,320.63,75,,,percent of total billed charges,75% of total billed charges,213.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,299.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,427.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,384.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.99,427.5,
DRSG CHITOSAN SPONGE 10X10CM,3614709,CDM,272,RC,,,Outpatient,,,773.5,464.1,,139.23,18,,,percent of total billed charges,pays at 18% of total charges,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.75,50,,,percent of total billed charges,pays at 50% of total billed charges,541.45,70,,,percent of total billed charges,70% of total billed charges,580.13,75,,,percent of total billed charges,75% of total billed charges,386.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,618.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,464.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,591.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,541.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,464.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,293.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,541.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,773.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,696.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.21,773.5,
SCREW CORTEX,3614710,CDM,278,RC,C1713,HCPCS,Outpatient,,,31.5,18.9,,5.67,18,,,percent of total billed charges,pays at 18% of total charges,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,70,,,percent of total billed charges,70% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,15.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,31.5,
DURAN ANULOPLSTY RING,3614713,CDM,278,RC,,,Outpatient,,,4148.5,2489.1,,746.73,18,,,percent of total billed charges,pays at 18% of total charges,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,746.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2074.25,50,,,percent of total billed charges,pays at 50% of total billed charges,2903.95,70,,,percent of total billed charges,70% of total billed charges,3111.38,75,,,percent of total billed charges,75% of total billed charges,2074.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3318.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2489.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4148.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1866.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2903.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2489.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1576.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2903.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1991.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4148.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4148.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,650.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.07,4148.5,
DRSG CHITOSAN SPONGE 10X20CM,3614714,CDM,272,RC,,,Outpatient,,,1163.5,698.1,,209.43,18,,,percent of total billed charges,pays at 18% of total charges,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,209.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,581.75,50,,,percent of total billed charges,pays at 50% of total billed charges,814.45,70,,,percent of total billed charges,70% of total billed charges,872.63,75,,,percent of total billed charges,75% of total billed charges,581.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,930.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,698.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,890.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,814.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,698.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,442.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,814.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1163.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1047.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.32,1163.5,
HEMOCLIP ALL SIZES,3614715,CDM,272,RC,,,Outpatient,,,98,58.8,,17.64,18,,,percent of total billed charges,pays at 18% of total charges,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49,50,,,percent of total billed charges,pays at 50% of total billed charges,68.6,70,,,percent of total billed charges,70% of total billed charges,73.5,75,,,percent of total billed charges,75% of total billed charges,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,98,
PLATE 16,3614718,CDM,278,RC,C1713,HCPCS,Outpatient,,,2335,1401,,420.3,18,,,percent of total billed charges,pays at 18% of total charges,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,420.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1634.5,70,,,percent of total billed charges,70% of total billed charges,1751.25,75,,,percent of total billed charges,75% of total billed charges,1167.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1868,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1401,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2335,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,402.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1634.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1401,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,887.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1634.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2335,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2335,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,365.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.89,2335,
SYS ORTHO MIXING,3614720,CDM,272,RC,,,Outpatient,,,585,351,,105.3,18,,,percent of total billed charges,pays at 18% of total charges,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.5,50,,,percent of total billed charges,pays at 50% of total billed charges,409.5,70,,,percent of total billed charges,70% of total billed charges,438.75,75,,,percent of total billed charges,75% of total billed charges,292.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,468,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,351,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,526.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.67,585,
DISSECTING TOOL TAC 125,3614724,CDM,272,RC,,,Outpatient,,,251,150.6,,45.18,18,,,percent of total billed charges,pays at 18% of total charges,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.5,50,,,percent of total billed charges,pays at 50% of total billed charges,175.7,70,,,percent of total billed charges,70% of total billed charges,188.25,75,,,percent of total billed charges,75% of total billed charges,125.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,251,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.33,251,
INTRODUCER SHEATH,3614725,CDM,272,RC,C1893,HCPCS,Outpatient,,,147,88.2,,26.46,18,,,percent of total billed charges,pays at 18% of total charges,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,73.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,147,
INTRODUCER SHEATH CORONARY,3614726,CDM,272,RC,C1893,HCPCS,Outpatient,,,17.5,10.5,,3.15,18,,,percent of total billed charges,pays at 18% of total charges,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.25,70,,,percent of total billed charges,70% of total billed charges,13.13,75,,,percent of total billed charges,75% of total billed charges,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.74,17.5,
FEMORAL STEM,3614733,CDM,278,RC,C1776,HCPCS,Outpatient,,,5551.5,3330.9,,999.27,18,,,percent of total billed charges,pays at 18% of total charges,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,999.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3886.05,70,,,percent of total billed charges,70% of total billed charges,4163.63,75,,,percent of total billed charges,75% of total billed charges,2775.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4441.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3330.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5551.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,956.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2498.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3886.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3330.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2109.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3886.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2664.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5551.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5551.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.92,5551.5,
FEMORAL HEAD,3614734,CDM,278,RC,C1776,HCPCS,Outpatient,,,1145,687,,206.1,18,,,percent of total billed charges,pays at 18% of total charges,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.5,70,,,percent of total billed charges,70% of total billed charges,858.75,75,,,percent of total billed charges,75% of total billed charges,572.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,687,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1145,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,197.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,801.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,687,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,435.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,801.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1145,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1145,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.42,1145,
SCREW EXT,3614739,CDM,278,RC,C1713,HCPCS,Outpatient,,,114.5,68.7,,20.61,18,,,percent of total billed charges,pays at 18% of total charges,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.15,70,,,percent of total billed charges,70% of total billed charges,85.88,75,,,percent of total billed charges,75% of total billed charges,57.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,114.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,114.5,
HUMERAL STEM,3614741,CDM,278,RC,C1776,HCPCS,Outpatient,,,11056.5,6633.9,,1990.17,18,,,percent of total billed charges,pays at 18% of total charges,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1990.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7739.55,70,,,percent of total billed charges,70% of total billed charges,8292.38,75,,,percent of total billed charges,75% of total billed charges,5528.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8845.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6633.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11056.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1905.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4975.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7739.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6633.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4201.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7739.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5307.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11056.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11056.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1732.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1732.55,11056.5,
HUMERAL INSERT,3614742,CDM,278,RC,C1776,HCPCS,Outpatient,,,3208,1924.8,,577.44,18,,,percent of total billed charges,pays at 18% of total charges,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2245.6,70,,,percent of total billed charges,70% of total billed charges,2406,75,,,percent of total billed charges,75% of total billed charges,1604,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2566.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1924.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3208,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,552.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1443.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1924.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1219.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2245.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1539.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,502.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.69,3208,
PENILE PUMP UROLOME,3614746,CDM,278,RC,C1813,HCPCS,Outpatient,,,6136,3681.6,,1104.48,18,,,percent of total billed charges,pays at 18% of total charges,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1104.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4295.2,70,,,percent of total billed charges,70% of total billed charges,4602,75,,,percent of total billed charges,75% of total billed charges,3068,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4908.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3681.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6136,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1057.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2761.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4295.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3681.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2331.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4295.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2945.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6136,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6136,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.51,6136,
GLENOID FIN,3614753,CDM,278,RC,C1776,HCPCS,Outpatient,,,1554,932.4,,279.72,18,,,percent of total billed charges,pays at 18% of total charges,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1087.8,70,,,percent of total billed charges,70% of total billed charges,1165.5,75,,,percent of total billed charges,75% of total billed charges,777,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1243.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,932.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1554,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,267.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1087.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,932.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,590.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1087.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,745.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1554,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1554,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.51,1554,
GLENOID GUIDE,3614756,CDM,272,RC,,,Outpatient,,,1755,1053,,315.9,18,,,percent of total billed charges,pays at 18% of total charges,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,877.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1228.5,70,,,percent of total billed charges,70% of total billed charges,1316.25,75,,,percent of total billed charges,75% of total billed charges,877.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1053,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1342.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1228.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1053,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1228.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,842.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1755,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1579.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.01,1755,
STEM HUMERAL,3614757,CDM,278,RC,C1776,HCPCS,Outpatient,,,2246,1347.6,,404.28,18,,,percent of total billed charges,pays at 18% of total charges,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572.2,70,,,percent of total billed charges,70% of total billed charges,1684.5,75,,,percent of total billed charges,75% of total billed charges,1123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1347.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2246,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,386.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1010.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1572.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1347.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,853.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1572.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1078.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2246,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2246,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.95,2246,
SCREW,3614758,CDM,278,RC,C1713,HCPCS,Outpatient,,,276,165.6,,49.68,18,,,percent of total billed charges,pays at 18% of total charges,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.2,70,,,percent of total billed charges,70% of total billed charges,207,75,,,percent of total billed charges,75% of total billed charges,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,276,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,276,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.25,276,
KIT MULTI ANCHOR,3614760,CDM,278,RC,C1713,HCPCS,Outpatient,,,5844,3506.4,,1051.92,18,,,percent of total billed charges,pays at 18% of total charges,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1051.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4090.8,70,,,percent of total billed charges,70% of total billed charges,4383,75,,,percent of total billed charges,75% of total billed charges,2922,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4675.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3506.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5844,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1006.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2629.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4090.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3506.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2220.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4090.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2805.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5844,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5844,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,915.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.75,5844,
MATRIX ORTHO DYNAMIC,3614762,CDM,278,RC,C1713,HCPCS,Outpatient,,,3426,2055.6,,616.68,18,,,percent of total billed charges,pays at 18% of total charges,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2398.2,70,,,percent of total billed charges,70% of total billed charges,2569.5,75,,,percent of total billed charges,75% of total billed charges,1713,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2055.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3426,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,590.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1541.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2398.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2055.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1301.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2398.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1644.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3426,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3426,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.85,3426,
KIT TOTAL HIP,3614767,CDM,272,RC,,,Outpatient,,,326.5,195.9,,58.77,18,,,percent of total billed charges,pays at 18% of total charges,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.25,50,,,percent of total billed charges,pays at 50% of total billed charges,228.55,70,,,percent of total billed charges,70% of total billed charges,244.88,75,,,percent of total billed charges,75% of total billed charges,163.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,228.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,228.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,293.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.16,326.5,
BONE CEMENT,3614768,CDM,278,RC,C1713,HCPCS,Outpatient,,,278.5,167.1,,50.13,18,,,percent of total billed charges,pays at 18% of total charges,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.95,70,,,percent of total billed charges,70% of total billed charges,208.88,75,,,percent of total billed charges,75% of total billed charges,139.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,278.5,
KIT ANCHOR DISP,3614771,CDM,272,RC,,,Outpatient,,,286.5,171.9,,51.57,18,,,percent of total billed charges,pays at 18% of total charges,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.25,50,,,percent of total billed charges,pays at 50% of total billed charges,200.55,70,,,percent of total billed charges,70% of total billed charges,214.88,75,,,percent of total billed charges,75% of total billed charges,143.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,229.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,286.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,257.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.89,286.5,
ROD 75MM,3614772,CDM,278,RC,,,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.5,50,,,percent of total billed charges,pays at 50% of total billed charges,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,333,
SCREW BIO INTERFERENCE,3614773,CDM,278,RC,C1713,HCPCS,Outpatient,,,391.5,234.9,,70.47,18,,,percent of total billed charges,pays at 18% of total charges,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.05,70,,,percent of total billed charges,70% of total billed charges,293.63,75,,,percent of total billed charges,75% of total billed charges,195.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,313.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,274.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,274.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,391.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,391.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.35,391.5,
ANCHOR SUTURE KIT W/ ORTHOCORD,3614774,CDM,278,RC,C1713,HCPCS,Outpatient,,,840,504,,151.2,18,,,percent of total billed charges,pays at 18% of total charges,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588,70,,,percent of total billed charges,70% of total billed charges,630,75,,,percent of total billed charges,75% of total billed charges,420,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,504,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,840,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,504,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,840,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,840,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.63,840,
PLATE VECTRA,3614775,CDM,278,RC,C1713,HCPCS,Outpatient,,,2948.5,1769.1,,530.73,18,,,percent of total billed charges,pays at 18% of total charges,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2063.95,70,,,percent of total billed charges,70% of total billed charges,2211.38,75,,,percent of total billed charges,75% of total billed charges,1474.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2358.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1769.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2948.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,508.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2063.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1769.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1120.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2063.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2948.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2948.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,462.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462.03,2948.5,
FEMORAL STEM,3614776,CDM,278,RC,C1776,HCPCS,Outpatient,,,2838,1702.8,,510.84,18,,,percent of total billed charges,pays at 18% of total charges,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,510.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1986.6,70,,,percent of total billed charges,70% of total billed charges,2128.5,75,,,percent of total billed charges,75% of total billed charges,1419,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1702.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2838,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,488.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1277.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1986.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1702.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1078.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1986.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1362.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2838,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2838,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.71,2838,
CATH BILIARY,3614780,CDM,272,RC,C1729,HCPCS,Outpatient,,,135,81,,24.3,18,,,percent of total billed charges,pays at 18% of total charges,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,135,
TAP,3614796,CDM,272,RC,,,Outpatient,,,550,330,,99,18,,,percent of total billed charges,pays at 18% of total charges,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275,50,,,percent of total billed charges,pays at 50% of total billed charges,385,70,,,percent of total billed charges,70% of total billed charges,412.5,75,,,percent of total billed charges,75% of total billed charges,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,495,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.19,550,
NUT LOCK,3614799,CDM,278,RC,,,Outpatient,,,79,47.4,,14.22,18,,,percent of total billed charges,pays at 18% of total charges,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.5,50,,,percent of total billed charges,pays at 50% of total billed charges,55.3,70,,,percent of total billed charges,70% of total billed charges,59.25,75,,,percent of total billed charges,75% of total billed charges,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,79,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,79,
CLAMP MULTI PIN,3614806,CDM,272,RC,,,Outpatient,,,1100,660,,198,18,,,percent of total billed charges,pays at 18% of total charges,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,550,50,,,percent of total billed charges,pays at 50% of total billed charges,770,70,,,percent of total billed charges,70% of total billed charges,825,75,,,percent of total billed charges,75% of total billed charges,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,660,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,841.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,770,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,660,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,770,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,990,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.37,1100,
DRILL BIT & PIN,3614807,CDM,272,RC,,,Outpatient,,,406.5,243.9,,73.17,18,,,percent of total billed charges,pays at 18% of total charges,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.25,50,,,percent of total billed charges,pays at 50% of total billed charges,284.55,70,,,percent of total billed charges,70% of total billed charges,304.88,75,,,percent of total billed charges,75% of total billed charges,203.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,325.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,284.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,284.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,406.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,365.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.7,406.5,
PIN DOCKING DISP,3614809,CDM,272,RC,,,Outpatient,,,573.3,343.98,,103.19,18,,,percent of total billed charges,pays at 18% of total charges,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.65,50,,,percent of total billed charges,pays at 50% of total billed charges,401.31,70,,,percent of total billed charges,70% of total billed charges,429.98,75,,,percent of total billed charges,75% of total billed charges,286.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,458.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,438.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,401.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,401.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,573.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,515.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.84,573.3,
CLIP SPRING DISP,3614816,CDM,272,RC,,,Outpatient,,,465.4,279.24,,83.77,18,,,percent of total billed charges,pays at 18% of total charges,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.7,50,,,percent of total billed charges,pays at 50% of total billed charges,325.78,70,,,percent of total billed charges,70% of total billed charges,349.05,75,,,percent of total billed charges,75% of total billed charges,232.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,356.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,325.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,325.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,465.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,418.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.93,465.4,
CRYOANALGESIA TIP,3614818,CDM,272,RC,,,Outpatient,,,520,312,,93.6,18,,,percent of total billed charges,pays at 18% of total charges,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260,50,,,percent of total billed charges,pays at 50% of total billed charges,364,70,,,percent of total billed charges,70% of total billed charges,390,75,,,percent of total billed charges,75% of total billed charges,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,468,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,520,
CRYOANALGESIA  CARTRIDGE,3614820,CDM,272,RC,,,Outpatient,,,129.45,77.67,,23.3,18,,,percent of total billed charges,pays at 18% of total charges,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.73,50,,,percent of total billed charges,pays at 50% of total billed charges,90.62,70,,,percent of total billed charges,70% of total billed charges,97.09,75,,,percent of total billed charges,75% of total billed charges,64.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,90.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,129.45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.28,129.45,
PUTTY DBX 2.5CC,3614823,CDM,278,RC,C9359,HCPCS,Outpatient,,,816,489.6,,146.88,18,,,percent of total billed charges,pays at 18% of total charges,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408,50,,,percent of total billed charges,pays at 50% of total billed charges,571.2,70,,,percent of total billed charges,70% of total billed charges,612,75,,,percent of total billed charges,75% of total billed charges,408,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,652.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,489.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,816,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,140.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,571.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,489.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,571.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,816,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,816,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.87,816,
PROBE LITHOTRIPTOR,3614834,CDM,272,RC,,,Outpatient,,,453.5,272.1,,81.63,18,,,percent of total billed charges,pays at 18% of total charges,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.75,50,,,percent of total billed charges,pays at 50% of total billed charges,317.45,70,,,percent of total billed charges,70% of total billed charges,340.13,75,,,percent of total billed charges,75% of total billed charges,226.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,362.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,317.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,272.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,317.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,453.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,408.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.06,453.5,
PROBE LITHOTRIPTOR,3614835,CDM,272,RC,,,Outpatient,,,838.43,503.06,,150.92,18,,,percent of total billed charges,pays at 18% of total charges,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,419.22,50,,,percent of total billed charges,pays at 50% of total billed charges,586.9,70,,,percent of total billed charges,70% of total billed charges,628.82,75,,,percent of total billed charges,75% of total billed charges,419.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,670.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,641.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,586.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,586.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.45,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,838.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,754.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.38,838.43,
BIOCORKSCREW 5.0 M NEEDLE,3614837,CDM,278,RC,C1713,HCPCS,Outpatient,,,798,478.8,,143.64,18,,,percent of total billed charges,pays at 18% of total charges,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.6,70,,,percent of total billed charges,70% of total billed charges,598.5,75,,,percent of total billed charges,75% of total billed charges,399,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,638.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,478.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,798,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,558.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,478.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,558.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,798,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,798,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.05,798,
GOLD WEIGHT 1GM,3614838,CDM,278,RC,,,Outpatient,,,554.5,332.7,,99.81,18,,,percent of total billed charges,pays at 18% of total charges,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.25,50,,,percent of total billed charges,pays at 50% of total billed charges,388.15,70,,,percent of total billed charges,70% of total billed charges,415.88,75,,,percent of total billed charges,75% of total billed charges,277.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,554.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,388.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,388.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,554.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,554.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.89,554.5,
INSERT PLATE,3614842,CDM,278,RC,,,Outpatient,,,101,60.6,,18.18,18,,,percent of total billed charges,pays at 18% of total charges,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.5,50,,,percent of total billed charges,pays at 50% of total billed charges,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,101,
ROD 50MM,3614843,CDM,278,RC,,,Outpatient,,,220.5,132.3,,39.69,18,,,percent of total billed charges,pays at 18% of total charges,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.25,50,,,percent of total billed charges,pays at 50% of total billed charges,154.35,70,,,percent of total billed charges,70% of total billed charges,165.38,75,,,percent of total billed charges,75% of total billed charges,110.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,154.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.55,220.5,
WASHERLOC FIXATION,3614856,CDM,278,RC,C1713,HCPCS,Outpatient,,,757,454.2,,136.26,18,,,percent of total billed charges,pays at 18% of total charges,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.9,70,,,percent of total billed charges,70% of total billed charges,567.75,75,,,percent of total billed charges,75% of total billed charges,378.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,757,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,529.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,454.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,529.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,757,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,757,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.62,757,
FEMORAL COMP,3614883,CDM,278,RC,C1776,HCPCS,Outpatient,,,1560,936,,280.8,18,,,percent of total billed charges,pays at 18% of total charges,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092,70,,,percent of total billed charges,70% of total billed charges,1170,75,,,percent of total billed charges,75% of total billed charges,780,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1560,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.45,1560,
SCREW CANCELLOUS,3614887,CDM,278,RC,C1713,HCPCS,Outpatient,,,302.5,181.5,,54.45,18,,,percent of total billed charges,pays at 18% of total charges,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.75,70,,,percent of total billed charges,70% of total billed charges,226.88,75,,,percent of total billed charges,75% of total billed charges,151.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,211.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.4,302.5,
SUCTION COAG W/HANDSWITCH,3614892,CDM,272,RC,,,Outpatient,,,31,18.6,,5.58,18,,,percent of total billed charges,pays at 18% of total charges,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.5,50,,,percent of total billed charges,pays at 50% of total billed charges,21.7,70,,,percent of total billed charges,70% of total billed charges,23.25,75,,,percent of total billed charges,75% of total billed charges,15.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,21.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,31,
ROD CVD,3614896,CDM,278,RC,C1713,HCPCS,Outpatient,,,516.5,309.9,,92.97,18,,,percent of total billed charges,pays at 18% of total charges,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.55,70,,,percent of total billed charges,70% of total billed charges,387.38,75,,,percent of total billed charges,75% of total billed charges,258.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,413.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,516.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,361.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,361.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,516.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,516.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.94,516.5,
BIOPSY PORT SEAL,3614897,CDM,272,RC,,,Outpatient,,,35.5,21.3,,6.39,18,,,percent of total billed charges,pays at 18% of total charges,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.75,50,,,percent of total billed charges,pays at 50% of total billed charges,24.85,70,,,percent of total billed charges,70% of total billed charges,26.63,75,,,percent of total billed charges,75% of total billed charges,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.56,35.5,
DRILL BIT,3614900,CDM,272,RC,,,Outpatient,,,479,287.4,,86.22,18,,,percent of total billed charges,pays at 18% of total charges,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.5,50,,,percent of total billed charges,pays at 50% of total billed charges,335.3,70,,,percent of total billed charges,70% of total billed charges,359.25,75,,,percent of total billed charges,75% of total billed charges,239.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,383.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,366.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,479,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,431.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.06,479,
KNIFE SHEATHED METRX,3614903,CDM,272,RC,,,Outpatient,,,498.5,299.1,,89.73,18,,,percent of total billed charges,pays at 18% of total charges,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.25,50,,,percent of total billed charges,pays at 50% of total billed charges,348.95,70,,,percent of total billed charges,70% of total billed charges,373.88,75,,,percent of total billed charges,75% of total billed charges,249.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,398.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,381.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,299.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,348.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,498.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.11,498.5,
NAIL TROCHANTERIC,3614906,CDM,278,RC,C1713,HCPCS,Outpatient,,,3600,2160,,648,18,,,percent of total billed charges,pays at 18% of total charges,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,648,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,70,,,percent of total billed charges,70% of total billed charges,2700,75,,,percent of total billed charges,75% of total billed charges,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,620.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1368,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.12,3600,
FEMORAL STEM,3614912,CDM,278,RC,C1776,HCPCS,Outpatient,,,8101,4860.6,,1458.18,18,,,percent of total billed charges,pays at 18% of total charges,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1458.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670.7,70,,,percent of total billed charges,70% of total billed charges,6075.75,75,,,percent of total billed charges,75% of total billed charges,4050.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4860.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8101,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1395.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3645.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5670.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4860.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3078.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5670.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3888.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1269.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1269.43,8101,
ELECTRODE AXS,3614919,CDM,272,RC,,,Outpatient,,,396,237.6,,71.28,18,,,percent of total billed charges,pays at 18% of total charges,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198,50,,,percent of total billed charges,pays at 50% of total billed charges,277.2,70,,,percent of total billed charges,70% of total billed charges,297,75,,,percent of total billed charges,75% of total billed charges,198,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,237.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,396,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,356.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.05,396,
DRAIN HEMOVAC,3614925,CDM,272,RC,C1729,HCPCS,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
BLADE SAW,3614935,CDM,272,RC,,,Outpatient,,,127,76.2,,22.86,18,,,percent of total billed charges,pays at 18% of total charges,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,50,,,percent of total billed charges,pays at 50% of total billed charges,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,63.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,127,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,114.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,127,
PLATE BUTTRESS,3614948,CDM,278,RC,C1713,HCPCS,Outpatient,,,4365.4,2619.24,,785.77,18,,,percent of total billed charges,pays at 18% of total charges,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,785.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3055.78,70,,,percent of total billed charges,70% of total billed charges,3274.05,75,,,percent of total billed charges,75% of total billed charges,2182.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3492.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2619.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4365.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,752.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1964.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3055.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2619.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1658.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3055.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2095.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4365.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4365.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.06,4365.4,
PLATE BUTTRESS,3614949,CDM,278,RC,C1713,HCPCS,Outpatient,,,951.5,570.9,,171.27,18,,,percent of total billed charges,pays at 18% of total charges,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.05,70,,,percent of total billed charges,70% of total billed charges,713.63,75,,,percent of total billed charges,75% of total billed charges,475.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,761.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,951.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,163.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,666.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,570.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,666.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,951.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,951.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.1,951.5,
KIT REVISION,3614950,CDM,272,RC,,,Outpatient,,,492.5,295.5,,88.65,18,,,percent of total billed charges,pays at 18% of total charges,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.25,50,,,percent of total billed charges,pays at 50% of total billed charges,344.75,70,,,percent of total billed charges,70% of total billed charges,369.38,75,,,percent of total billed charges,75% of total billed charges,246.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,295.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,344.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,344.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,492.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,443.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.17,492.5,
ANCHOR SUTURE BIOKNOTLESS,3614958,CDM,278,RC,C1713,HCPCS,Outpatient,,,667,400.2,,120.06,18,,,percent of total billed charges,pays at 18% of total charges,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.9,70,,,percent of total billed charges,70% of total billed charges,500.25,75,,,percent of total billed charges,75% of total billed charges,333.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,533.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,667,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,466.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,466.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,667,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,667,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.52,667,
PLATE CLAVICLE HOOK LCP,3614961,CDM,278,RC,C1713,HCPCS,Outpatient,,,1076.5,645.9,,193.77,18,,,percent of total billed charges,pays at 18% of total charges,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,753.55,70,,,percent of total billed charges,70% of total billed charges,807.38,75,,,percent of total billed charges,75% of total billed charges,538.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1076.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,185.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,753.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,753.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1076.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1076.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.69,1076.5,
PLATE CALCANEAL,3614964,CDM,278,RC,C1713,HCPCS,Outpatient,,,931.5,558.9,,167.67,18,,,percent of total billed charges,pays at 18% of total charges,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.05,70,,,percent of total billed charges,70% of total billed charges,698.63,75,,,percent of total billed charges,75% of total billed charges,465.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,745.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,558.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,931.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,652.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,558.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,652.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,931.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,931.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.97,931.5,
SCREW LCKG 2.4,3614965,CDM,278,RC,C1713,HCPCS,Outpatient,,,192,115.2,,34.56,18,,,percent of total billed charges,pays at 18% of total charges,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,70,,,percent of total billed charges,70% of total billed charges,144,75,,,percent of total billed charges,75% of total billed charges,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,192,
SCREW NON-LCKG,3614967,CDM,278,RC,C1713,HCPCS,Outpatient,,,158.5,95.1,,28.53,18,,,percent of total billed charges,pays at 18% of total charges,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.95,70,,,percent of total billed charges,70% of total billed charges,118.88,75,,,percent of total billed charges,75% of total billed charges,79.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,158.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,158.5,
PLATE TIBIAL DIST LCKG,3615003,CDM,278,RC,C1713,HCPCS,Outpatient,,,2093.5,1256.1,,376.83,18,,,percent of total billed charges,pays at 18% of total charges,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1465.45,70,,,percent of total billed charges,70% of total billed charges,1570.13,75,,,percent of total billed charges,75% of total billed charges,1046.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1674.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1256.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2093.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,360.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,942.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1465.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1256.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1465.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2093.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2093.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.05,2093.5,
BAG PRESSURE LGE,3615006,CDM,272,RC,,,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,50,,,percent of total billed charges,pays at 50% of total billed charges,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,125,
ANCHOR SUTURE,3615007,CDM,278,RC,C1713,HCPCS,Outpatient,,,637.5,382.5,,114.75,18,,,percent of total billed charges,pays at 18% of total charges,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.25,70,,,percent of total billed charges,70% of total billed charges,478.13,75,,,percent of total billed charges,75% of total billed charges,318.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,446.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,446.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,637.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,637.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.9,637.5,
SET FRONTALIS SUSPENSION,3615013,CDM,272,RC,,,Outpatient,,,131.5,78.9,,23.67,18,,,percent of total billed charges,pays at 18% of total charges,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.75,50,,,percent of total billed charges,pays at 50% of total billed charges,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,65.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,131.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.61,131.5,
BANDAGE ACE 6 IN,3615014,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SCREW SLF DRLG,3615018,CDM,278,RC,C1713,HCPCS,Outpatient,,,1405,843,,252.9,18,,,percent of total billed charges,pays at 18% of total charges,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.5,70,,,percent of total billed charges,70% of total billed charges,1053.75,75,,,percent of total billed charges,75% of total billed charges,702.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,843,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1405,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,242.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,632.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,983.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,843,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,983.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1405,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1405,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.16,1405,
PIN STEINMAN,3615040,CDM,278,RC,C1713,HCPCS,Outpatient,,,420,252,,75.6,18,,,percent of total billed charges,pays at 18% of total charges,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294,70,,,percent of total billed charges,70% of total billed charges,315,75,,,percent of total billed charges,75% of total billed charges,210,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,336,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,294,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,252,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,294,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,420,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,420,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.81,420,
TIBIAL BASE,3615041,CDM,278,RC,C1776,HCPCS,Outpatient,,,825,495,,148.5,18,,,percent of total billed charges,pays at 18% of total charges,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.5,70,,,percent of total billed charges,70% of total billed charges,618.75,75,,,percent of total billed charges,75% of total billed charges,412.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,495,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,825,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,495,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,577.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.28,825,
TIBIAL BASE W PLUG,3615043,CDM,278,RC,C1776,HCPCS,Outpatient,,,4280.9,2568.54,,770.56,18,,,percent of total billed charges,pays at 18% of total charges,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,770.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2996.63,70,,,percent of total billed charges,70% of total billed charges,3210.68,75,,,percent of total billed charges,75% of total billed charges,2140.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3424.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2568.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4280.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,737.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2996.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2568.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1626.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2996.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2054.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4280.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4280.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,670.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.82,4280.9,
SCREW 6.5,3615045,CDM,278,RC,C1713,HCPCS,Outpatient,,,250,150,,45,18,,,percent of total billed charges,pays at 18% of total charges,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,70,,,percent of total billed charges,70% of total billed charges,187.5,75,,,percent of total billed charges,75% of total billed charges,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.18,250,
TIBIAL SLEEVE,3615047,CDM,278,RC,C1776,HCPCS,Outpatient,,,4293.9,2576.34,,772.9,18,,,percent of total billed charges,pays at 18% of total charges,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3005.73,70,,,percent of total billed charges,70% of total billed charges,3220.43,75,,,percent of total billed charges,75% of total billed charges,2146.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3435.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2576.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4293.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,739.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1932.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3005.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2576.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1631.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3005.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2061.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4293.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4293.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.85,4293.9,
TIBIAL BASE,3615048,CDM,278,RC,C1776,HCPCS,Outpatient,,,5837,3502.2,,1050.66,18,,,percent of total billed charges,pays at 18% of total charges,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1050.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4085.9,70,,,percent of total billed charges,70% of total billed charges,4377.75,75,,,percent of total billed charges,75% of total billed charges,2918.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4669.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3502.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5837,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1005.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2626.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4085.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3502.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2218.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4085.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5837,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5837,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,914.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,914.66,5837,
TIBIAL BASEPLATE,3615049,CDM,278,RC,C1776,HCPCS,Outpatient,,,1430,858,,257.4,18,,,percent of total billed charges,pays at 18% of total charges,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001,70,,,percent of total billed charges,70% of total billed charges,1072.5,75,,,percent of total billed charges,75% of total billed charges,715,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,858,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1430,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1001,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,858,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,543.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1001,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1430,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1430,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.08,1430,
PLATE TIBIAL PROX,3615060,CDM,278,RC,,,Outpatient,,,1326,795.6,,238.68,18,,,percent of total billed charges,pays at 18% of total charges,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,663,50,,,percent of total billed charges,pays at 50% of total billed charges,928.2,70,,,percent of total billed charges,70% of total billed charges,994.5,75,,,percent of total billed charges,75% of total billed charges,663,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1326,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,928.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,928.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1326,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1326,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.78,1326,
TIBIA BASEPLATE,3615063,CDM,278,RC,C1776,HCPCS,Outpatient,,,1950,1170,,351,18,,,percent of total billed charges,pays at 18% of total charges,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,70,,,percent of total billed charges,70% of total billed charges,1462.5,75,,,percent of total billed charges,75% of total billed charges,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,741,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.57,1950,
FILIFORM COUDE,3615074,CDM,272,RC,,,Outpatient,,,85,51,,15.3,18,,,percent of total billed charges,pays at 18% of total charges,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.5,50,,,percent of total billed charges,pays at 50% of total billed charges,59.5,70,,,percent of total billed charges,70% of total billed charges,63.75,75,,,percent of total billed charges,75% of total billed charges,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,85,
CANNULA OSTIAL,3615098,CDM,272,RC,,,Outpatient,,,96,57.6,,17.28,18,,,percent of total billed charges,pays at 18% of total charges,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48,50,,,percent of total billed charges,pays at 50% of total billed charges,67.2,70,,,percent of total billed charges,70% of total billed charges,72,75,,,percent of total billed charges,75% of total billed charges,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,96,
HEMO LOK MED LG,3615099,CDM,272,RC,,,Outpatient,,,58,34.8,,10.44,18,,,percent of total billed charges,pays at 18% of total charges,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29,50,,,percent of total billed charges,pays at 50% of total billed charges,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,58,
DRESSING ADAPTIC,3615100,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
DRIVERS DISP,3615104,CDM,272,RC,,,Outpatient,,,521,312.6,,93.78,18,,,percent of total billed charges,pays at 18% of total charges,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.5,50,,,percent of total billed charges,pays at 50% of total billed charges,364.7,70,,,percent of total billed charges,70% of total billed charges,390.75,75,,,percent of total billed charges,75% of total billed charges,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,398.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,521,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,468.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.64,521,
DRESSING ADAPTIC,3615105,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
KIT INTERFERENCE SCREW DISP,3615106,CDM,278,RC,,,Outpatient,,,608,364.8,,109.44,18,,,percent of total billed charges,pays at 18% of total charges,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304,50,,,percent of total billed charges,pays at 50% of total billed charges,425.6,70,,,percent of total billed charges,70% of total billed charges,456,75,,,percent of total billed charges,75% of total billed charges,304,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,486.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,364.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,608,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,425.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,364.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,425.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,608,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,608,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,608,
SURGIFLO SEALANT HEMOSTATANT,3615115,CDM,272,RC,,,Outpatient,,,401.5,240.9,,72.27,18,,,percent of total billed charges,pays at 18% of total charges,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.75,50,,,percent of total billed charges,pays at 50% of total billed charges,281.05,70,,,percent of total billed charges,70% of total billed charges,301.13,75,,,percent of total billed charges,75% of total billed charges,200.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,321.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,307.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,401.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,361.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.92,401.5,
CEMENT BONE ANTIBIOTIC,3615116,CDM,278,RC,C1713,HCPCS,Outpatient,,,685,411,,123.3,18,,,percent of total billed charges,pays at 18% of total charges,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,342.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,685,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,685,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,685,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.34,685,
APPLICATOR ENDOSCOPIC HEMOSTATIC,3615117,CDM,272,RC,,,Outpatient,,,78,46.8,,14.04,18,,,percent of total billed charges,pays at 18% of total charges,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39,50,,,percent of total billed charges,pays at 50% of total billed charges,54.6,70,,,percent of total billed charges,70% of total billed charges,58.5,75,,,percent of total billed charges,75% of total billed charges,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.22,78,
FIBERWIRE LOOP W NEEDLE,3615124,CDM,272,RC,,,Outpatient,,,179.5,107.7,,32.31,18,,,percent of total billed charges,pays at 18% of total charges,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.75,50,,,percent of total billed charges,pays at 50% of total billed charges,125.65,70,,,percent of total billed charges,70% of total billed charges,134.63,75,,,percent of total billed charges,75% of total billed charges,89.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,125.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,179.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,161.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,179.5,
DRESSING IODOFORM PACKING,3615127,CDM,272,RC,,,Outpatient,,,13.5,8.1,,2.43,18,,,percent of total billed charges,pays at 18% of total charges,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.75,50,,,percent of total billed charges,pays at 50% of total billed charges,9.45,70,,,percent of total billed charges,70% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,13.5,
DRESSING NUGAUZE PLN,3615136,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
DRESSING-SURGICEL 2 X 14,3615152,CDM,272,RC,,,Outpatient,,,75.5,45.3,,13.59,18,,,percent of total billed charges,pays at 18% of total charges,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.75,50,,,percent of total billed charges,pays at 50% of total billed charges,52.85,70,,,percent of total billed charges,70% of total billed charges,56.63,75,,,percent of total billed charges,75% of total billed charges,37.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,75.5,
DRESSING-SURGICEL 4 X 8,3615153,CDM,272,RC,,,Outpatient,,,115.5,69.3,,20.79,18,,,percent of total billed charges,pays at 18% of total charges,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,50,,,percent of total billed charges,pays at 50% of total billed charges,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,57.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,115.5,
DRESSING XEROFORM,3615183,CDM,272,RC,,,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
SCREW INNER,3615197,CDM,278,RC,C1713,HCPCS,Outpatient,,,126,75.6,,22.68,18,,,percent of total billed charges,pays at 18% of total charges,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,126,
TIBIAL INSERT,3615213,CDM,278,RC,C1776,HCPCS,Outpatient,,,2151.5,1290.9,,387.27,18,,,percent of total billed charges,pays at 18% of total charges,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1506.05,70,,,percent of total billed charges,70% of total billed charges,1613.63,75,,,percent of total billed charges,75% of total billed charges,1075.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1721.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1290.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2151.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,370.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,968.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1506.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1290.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,817.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1506.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1032.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2151.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2151.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.14,2151.5,
OSTEOTOME SERRATED,3615215,CDM,272,RC,,,Outpatient,,,1040,624,,187.2,18,,,percent of total billed charges,pays at 18% of total charges,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,1040,
NEURO DRILL DISP,3615220,CDM,272,RC,,,Outpatient,,,239.5,143.7,,43.11,18,,,percent of total billed charges,pays at 18% of total charges,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.75,50,,,percent of total billed charges,pays at 50% of total billed charges,167.65,70,,,percent of total billed charges,70% of total billed charges,179.63,75,,,percent of total billed charges,75% of total billed charges,119.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,167.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,215.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.53,239.5,
BLANKET ARTIC SUN,3615222,CDM,272,RC,,,Outpatient,,,549,329.4,,98.82,18,,,percent of total billed charges,pays at 18% of total charges,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.5,50,,,percent of total billed charges,pays at 50% of total billed charges,384.3,70,,,percent of total billed charges,70% of total billed charges,411.75,75,,,percent of total billed charges,75% of total billed charges,274.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,439.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,329.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,419.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,384.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,329.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,384.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,549,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,494.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.03,549,
LASER FIBER 200 MICRON,3615225,CDM,272,RC,,,Outpatient,,,952.5,571.5,,171.45,18,,,percent of total billed charges,pays at 18% of total charges,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,476.25,50,,,percent of total billed charges,pays at 50% of total billed charges,666.75,70,,,percent of total billed charges,70% of total billed charges,714.38,75,,,percent of total billed charges,75% of total billed charges,476.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,762,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,571.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,728.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,666.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,571.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,666.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,952.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,857.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.26,952.5,
LASER FIBER 400 MICRON,3615226,CDM,272,RC,,,Outpatient,,,667,400.2,,120.06,18,,,percent of total billed charges,pays at 18% of total charges,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.5,50,,,percent of total billed charges,pays at 50% of total billed charges,466.9,70,,,percent of total billed charges,70% of total billed charges,500.25,75,,,percent of total billed charges,75% of total billed charges,333.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,533.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,466.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,466.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,667,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,600.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.52,667,
CANNULA,3615228,CDM,272,RC,,,Outpatient,,,291,174.6,,52.38,18,,,percent of total billed charges,pays at 18% of total charges,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.5,50,,,percent of total billed charges,pays at 50% of total billed charges,203.7,70,,,percent of total billed charges,70% of total billed charges,218.25,75,,,percent of total billed charges,75% of total billed charges,145.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,203.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,291,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,261.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,291,
CANNULA FEMORAL,3615229,CDM,272,RC,,,Outpatient,,,509.6,305.76,,91.73,18,,,percent of total billed charges,pays at 18% of total charges,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.8,50,,,percent of total billed charges,pays at 50% of total billed charges,356.72,70,,,percent of total billed charges,70% of total billed charges,382.2,75,,,percent of total billed charges,75% of total billed charges,254.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,407.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,389.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,356.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,305.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,356.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,509.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,458.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.85,509.6,
KIT BIOPSY GUIDE STEALTH,3615230,CDM,272,RC,,,Outpatient,,,1709.5,1025.7,,307.71,18,,,percent of total billed charges,pays at 18% of total charges,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,854.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1196.65,70,,,percent of total billed charges,70% of total billed charges,1282.13,75,,,percent of total billed charges,75% of total billed charges,854.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1367.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1025.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1307.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1196.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1025.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,649.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1196.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1709.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1538.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.88,1709.5,
KIT BIOPSY NEEDLE STEALTH,3615231,CDM,272,RC,,,Outpatient,,,898.3,538.98,,161.69,18,,,percent of total billed charges,pays at 18% of total charges,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,449.15,50,,,percent of total billed charges,pays at 50% of total billed charges,628.81,70,,,percent of total billed charges,70% of total billed charges,673.73,75,,,percent of total billed charges,75% of total billed charges,449.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,718.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,538.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,687.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,628.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,538.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,628.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,898.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,808.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.76,898.3,
NAIL HUMERAL CANN,3615258,CDM,278,RC,C1713,HCPCS,Outpatient,,,2497.5,1498.5,,449.55,18,,,percent of total billed charges,pays at 18% of total charges,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1748.25,70,,,percent of total billed charges,70% of total billed charges,1873.13,75,,,percent of total billed charges,75% of total billed charges,1248.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1998,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1498.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2497.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,430.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1123.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1748.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1498.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,949.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1748.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2497.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2497.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.36,2497.5,
END CAP TI STRDRV,3615259,CDM,278,RC,C1713,HCPCS,Outpatient,,,394.42,236.65,,71,18,,,percent of total billed charges,pays at 18% of total charges,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.09,70,,,percent of total billed charges,70% of total billed charges,295.82,75,,,percent of total billed charges,75% of total billed charges,197.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,315.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,276.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,236.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,276.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,394.42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,394.42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.81,394.42,
SCREW LCKG TI,3615260,CDM,278,RC,C1713,HCPCS,Outpatient,,,275.5,165.3,,49.59,18,,,percent of total billed charges,pays at 18% of total charges,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.85,70,,,percent of total billed charges,70% of total billed charges,206.63,75,,,percent of total billed charges,75% of total billed charges,137.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.17,275.5,
SCREW CORT 2.4,3615263,CDM,278,RC,C1713,HCPCS,Outpatient,,,86,51.6,,15.48,18,,,percent of total billed charges,pays at 18% of total charges,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.2,70,,,percent of total billed charges,70% of total billed charges,64.5,75,,,percent of total billed charges,75% of total billed charges,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,86,
SCREW SLF TPNG,3615272,CDM,278,RC,C1713,HCPCS,Outpatient,,,590,354,,106.2,18,,,percent of total billed charges,pays at 18% of total charges,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413,70,,,percent of total billed charges,70% of total billed charges,442.5,75,,,percent of total billed charges,75% of total billed charges,295,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,472,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,590,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,413,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,354,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,413,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,590,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,590,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.45,590,
PLATE VENTURE,3615273,CDM,278,RC,C1713,HCPCS,Outpatient,,,2176.5,1305.9,,391.77,18,,,percent of total billed charges,pays at 18% of total charges,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1523.55,70,,,percent of total billed charges,70% of total billed charges,1632.38,75,,,percent of total billed charges,75% of total billed charges,1088.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1741.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1305.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2176.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,375.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1523.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1305.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,827.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1523.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2176.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2176.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.06,2176.5,
SPONGE AUTOCOUNT KITTNER,3615275,CDM,272,RC,,,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
SPONGE LAP ACCUSORB,3615290,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
SPONGE  LAP,3615292,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
PIN CERCLAGE,3615335,CDM,278,RC,C1713,HCPCS,Outpatient,,,248.5,149.1,,44.73,18,,,percent of total billed charges,pays at 18% of total charges,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.95,70,,,percent of total billed charges,70% of total billed charges,186.38,75,,,percent of total billed charges,75% of total billed charges,124.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,248.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,248.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.94,248.5,
SYS FIX WRIST,3615337,CDM,278,RC,C1713,HCPCS,Outpatient,,,2401.5,1440.9,,432.27,18,,,percent of total billed charges,pays at 18% of total charges,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1681.05,70,,,percent of total billed charges,70% of total billed charges,1801.13,75,,,percent of total billed charges,75% of total billed charges,1200.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1921.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2401.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,413.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1681.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1440.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,912.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1681.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1152.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2401.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2401.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.32,2401.5,
BONE FLAP,3615338,CDM,278,RC,,,Outpatient,,,23225,13935,,4180.5,18,,,percent of total billed charges,pays at 18% of total charges,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4180.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11612.5,50,,,percent of total billed charges,pays at 50% of total billed charges,16257.5,70,,,percent of total billed charges,70% of total billed charges,17418.75,75,,,percent of total billed charges,75% of total billed charges,11612.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13935,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23225,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10451.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16257.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13935,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8825.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16257.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11148,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3639.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3639.36,23225,
TIBIAL INSERT,3615344,CDM,278,RC,C1776,HCPCS,Outpatient,,,3035.5,1821.3,,546.39,18,,,percent of total billed charges,pays at 18% of total charges,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2124.85,70,,,percent of total billed charges,70% of total billed charges,2276.63,75,,,percent of total billed charges,75% of total billed charges,1517.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2428.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1821.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3035.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,523.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2124.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1821.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1153.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2124.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1457.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3035.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3035.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.66,3035.5,
ACETABULAR LINER,3615346,CDM,278,RC,C1776,HCPCS,Outpatient,,,3277,1966.2,,589.86,18,,,percent of total billed charges,pays at 18% of total charges,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2293.9,70,,,percent of total billed charges,70% of total billed charges,2457.75,75,,,percent of total billed charges,75% of total billed charges,1638.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2621.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1966.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3277,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,564.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1474.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2293.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1966.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1245.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2293.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3277,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3277,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.51,3277,
SPACER CERVICAL,3615349,CDM,278,RC,C1821,HCPCS,Outpatient,,,2340,1404,,421.2,18,,,percent of total billed charges,pays at 18% of total charges,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,421.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638,70,,,percent of total billed charges,70% of total billed charges,1755,75,,,percent of total billed charges,75% of total billed charges,1170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1404,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,403.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1638,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1404,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,889.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1638,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1123.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.68,2340,
QUADRANT LIGHT SET,3615350,CDM,272,RC,,,Outpatient,,,1019.5,611.7,,183.51,18,,,percent of total billed charges,pays at 18% of total charges,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,509.75,50,,,percent of total billed charges,pays at 50% of total billed charges,713.65,70,,,percent of total billed charges,70% of total billed charges,764.63,75,,,percent of total billed charges,75% of total billed charges,509.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,815.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,611.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,779.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,713.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,611.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,713.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1019.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,917.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.76,1019.5,
SCREW CANN 6.5,3615352,CDM,278,RC,C1713,HCPCS,Outpatient,,,2785.5,1671.3,,501.39,18,,,percent of total billed charges,pays at 18% of total charges,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1949.85,70,,,percent of total billed charges,70% of total billed charges,2089.13,75,,,percent of total billed charges,75% of total billed charges,1392.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2228.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1671.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2785.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,479.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1253.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1949.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1671.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1058.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1949.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1337.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2785.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2785.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.49,2785.5,
SET INDWELLING SLIT CATH SET,3615353,CDM,272,RC,,,Outpatient,,,182.5,109.5,,32.85,18,,,percent of total billed charges,pays at 18% of total charges,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.25,50,,,percent of total billed charges,pays at 50% of total billed charges,127.75,70,,,percent of total billed charges,70% of total billed charges,136.88,75,,,percent of total billed charges,75% of total billed charges,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,182.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,164.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.6,182.5,
SCREW LEGACY,3615354,CDM,278,RC,C1713,HCPCS,Outpatient,,,2865,1719,,515.7,18,,,percent of total billed charges,pays at 18% of total charges,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2005.5,70,,,percent of total billed charges,70% of total billed charges,2148.75,75,,,percent of total billed charges,75% of total billed charges,1432.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1719,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2865,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,493.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1289.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2005.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1719,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1088.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2005.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1375.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2865,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2865,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.95,2865,
FEMORAL HEAD UNI,3615356,CDM,278,RC,C1776,HCPCS,Outpatient,,,4466.5,2679.9,,803.97,18,,,percent of total billed charges,pays at 18% of total charges,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,803.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3126.55,70,,,percent of total billed charges,70% of total billed charges,3349.88,75,,,percent of total billed charges,75% of total billed charges,2233.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3573.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2679.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4466.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,769.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2009.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3126.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2679.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1697.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3126.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2143.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4466.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4466.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,699.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.9,4466.5,
TIBIAL TRAY UNI,3615357,CDM,278,RC,C1776,HCPCS,Outpatient,,,3200.5,1920.3,,576.09,18,,,percent of total billed charges,pays at 18% of total charges,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,576.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.35,70,,,percent of total billed charges,70% of total billed charges,2400.38,75,,,percent of total billed charges,75% of total billed charges,1600.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2560.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3200.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,551.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1216.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2240.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.52,3200.5,
TIBIAL INSERT UNI,3615358,CDM,278,RC,C1776,HCPCS,Outpatient,,,1382,829.2,,248.76,18,,,percent of total billed charges,pays at 18% of total charges,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.4,70,,,percent of total billed charges,70% of total billed charges,1036.5,75,,,percent of total billed charges,75% of total billed charges,691,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,829.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1382,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,238.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,967.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,829.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,525.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,967.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1382,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1382,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.56,1382,
SPACER VERTEBRAE,3615359,CDM,278,RC,C1821,HCPCS,Outpatient,,,6555,3933,,1179.9,18,,,percent of total billed charges,pays at 18% of total charges,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1179.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4588.5,70,,,percent of total billed charges,70% of total billed charges,4916.25,75,,,percent of total billed charges,75% of total billed charges,3277.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3933,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6555,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1129.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2949.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4588.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3933,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2490.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4588.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3146.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6555,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6555,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1027.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.17,6555,
PENILE PROSTHESIS,3615364,CDM,278,RC,C1813,HCPCS,Outpatient,,,9450,5670,,1701,18,,,percent of total billed charges,pays at 18% of total charges,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1701,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6615,70,,,percent of total billed charges,70% of total billed charges,7087.5,75,,,percent of total billed charges,75% of total billed charges,4725,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5670,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9450,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1628.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4252.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6615,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5670,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3591,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6615,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1480.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.82,9450,
SCREW BIOTENDONESIS,3615365,CDM,278,RC,C1713,HCPCS,Outpatient,,,488.5,293.1,,87.93,18,,,percent of total billed charges,pays at 18% of total charges,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.95,70,,,percent of total billed charges,70% of total billed charges,366.38,75,,,percent of total billed charges,75% of total billed charges,244.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,390.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,488.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,341.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,293.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,341.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,488.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,488.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.55,488.5,
KIT ACL TIGHTROPE,3615366,CDM,278,RC,C1713,HCPCS,Outpatient,,,1098.5,659.1,,197.73,18,,,percent of total billed charges,pays at 18% of total charges,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.95,70,,,percent of total billed charges,70% of total billed charges,823.88,75,,,percent of total billed charges,75% of total billed charges,549.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,878.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,659.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1098.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,768.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,659.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,768.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1098.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1098.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.13,1098.5,
KIT SYNDESMOSIS REPAIR,3615367,CDM,278,RC,C1713,HCPCS,Outpatient,,,2776.8,1666.08,,499.82,18,,,percent of total billed charges,pays at 18% of total charges,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,499.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1943.76,70,,,percent of total billed charges,70% of total billed charges,2082.6,75,,,percent of total billed charges,75% of total billed charges,1388.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2221.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1666.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2776.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,478.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1943.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1666.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1055.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1943.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1332.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2776.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2776.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.12,2776.8,
STRIPPER VEIN DISP,3615368,CDM,272,RC,,,Outpatient,,,50.5,30.3,,9.09,18,,,percent of total billed charges,pays at 18% of total charges,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.25,50,,,percent of total billed charges,pays at 50% of total billed charges,35.35,70,,,percent of total billed charges,70% of total billed charges,37.88,75,,,percent of total billed charges,75% of total billed charges,25.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.91,50.5,
INSERT CVD SCISSORS,3615370,CDM,272,RC,,,Outpatient,,,137.5,82.5,,24.75,18,,,percent of total billed charges,pays at 18% of total charges,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.75,50,,,percent of total billed charges,pays at 50% of total billed charges,96.25,70,,,percent of total billed charges,70% of total billed charges,103.13,75,,,percent of total billed charges,75% of total billed charges,68.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,137.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,123.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.55,137.5,
GRANULE CHRONOS,3615374,CDM,278,RC,,,Outpatient,,,1311.5,786.9,,236.07,18,,,percent of total billed charges,pays at 18% of total charges,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,655.75,50,,,percent of total billed charges,pays at 50% of total billed charges,918.05,70,,,percent of total billed charges,70% of total billed charges,983.63,75,,,percent of total billed charges,75% of total billed charges,655.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1049.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,786.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1311.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,918.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,786.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,498.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,918.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1311.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1311.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.51,1311.5,
FORCEP BX URETEROSCOPY,3615375,CDM,272,RC,,,Outpatient,,,670.8,402.48,,120.74,18,,,percent of total billed charges,pays at 18% of total charges,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,335.4,50,,,percent of total billed charges,pays at 50% of total billed charges,469.56,70,,,percent of total billed charges,70% of total billed charges,503.1,75,,,percent of total billed charges,75% of total billed charges,335.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,513.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,469.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,469.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,670.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,603.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.11,670.8,
SCREW LCKG 2.7,3615376,CDM,278,RC,C1713,HCPCS,Outpatient,,,153.5,92.1,,27.63,18,,,percent of total billed charges,pays at 18% of total charges,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.45,70,,,percent of total billed charges,70% of total billed charges,115.13,75,,,percent of total billed charges,75% of total billed charges,76.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,107.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,153.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,153.5,
FORCEP BIPOLAR BAYONET,3615377,CDM,272,RC,,,Outpatient,,,1443,865.8,,259.74,18,,,percent of total billed charges,pays at 18% of total charges,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,721.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1010.1,70,,,percent of total billed charges,70% of total billed charges,1082.25,75,,,percent of total billed charges,75% of total billed charges,721.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1103.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1010.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,865.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,548.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1010.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1443,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1298.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.12,1443,
PROBE ELECTROSURGICAL W/SMOKE EVAC,3615379,CDM,272,RC,,,Outpatient,,,188,112.8,,33.84,18,,,percent of total billed charges,pays at 18% of total charges,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94,50,,,percent of total billed charges,pays at 50% of total billed charges,131.6,70,,,percent of total billed charges,70% of total billed charges,141,75,,,percent of total billed charges,75% of total billed charges,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,188,
ACETABULAR CUP/SHELL,3615380,CDM,278,RC,C1776,HCPCS,Outpatient,,,7095,4257,,1277.1,18,,,percent of total billed charges,pays at 18% of total charges,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1277.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4966.5,70,,,percent of total billed charges,70% of total billed charges,5321.25,75,,,percent of total billed charges,75% of total billed charges,3547.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4257,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7095,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1222.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3192.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4966.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4257,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2696.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4966.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3405.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7095,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7095,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1111.79,7095,
FEMORAL IMPLANT UNI,3615381,CDM,278,RC,C1776,HCPCS,Outpatient,,,2830,1698,,509.4,18,,,percent of total billed charges,pays at 18% of total charges,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1981,70,,,percent of total billed charges,70% of total billed charges,2122.5,75,,,percent of total billed charges,75% of total billed charges,1415,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1698,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2830,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,487.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1981,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1698,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1075.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1981,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1358.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2830,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2830,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.46,2830,
ADAPTER SLEEVE TAPER,3615382,CDM,278,RC,C1776,HCPCS,Outpatient,,,502,301.2,,90.36,18,,,percent of total billed charges,pays at 18% of total charges,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.4,70,,,percent of total billed charges,70% of total billed charges,376.5,75,,,percent of total billed charges,75% of total billed charges,251,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,401.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,502,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,351.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,502,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,502,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.66,502,
SCREW LCKG GUIDE,3615383,CDM,272,RC,C1713,HCPCS,Outpatient,,,157.5,94.5,,28.35,18,,,percent of total billed charges,pays at 18% of total charges,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,70,,,percent of total billed charges,70% of total billed charges,118.13,75,,,percent of total billed charges,75% of total billed charges,78.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,157.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,141.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,157.5,
SHUNT VENTRICULAR,3615385,CDM,278,RC,,,Outpatient,,,3609,2165.4,,649.62,18,,,percent of total billed charges,pays at 18% of total charges,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,649.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1804.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2526.3,70,,,percent of total billed charges,70% of total billed charges,2706.75,75,,,percent of total billed charges,75% of total billed charges,1804.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2165.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3609,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1624.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2526.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2165.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1371.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2526.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1732.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3609,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3609,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.53,3609,
ALLODERM MATRIX TISSUE,3615386,CDM,278,RC,C1762,HCPCS,Outpatient,,,2112.5,1267.5,,380.25,18,,,percent of total billed charges,pays at 18% of total charges,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1478.75,70,,,percent of total billed charges,70% of total billed charges,1584.38,75,,,percent of total billed charges,75% of total billed charges,1056.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1690,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1267.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2112.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,363.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1478.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1267.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1478.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.03,2112.5,
KYPHOPLASTY BIOPSY DEVICE,3615387,CDM,272,RC,,,Outpatient,,,197.5,118.5,,35.55,18,,,percent of total billed charges,pays at 18% of total charges,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,98.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,197.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,197.5,
ADAPTER SLEEVE,3615388,CDM,278,RC,C1776,HCPCS,Outpatient,,,940,564,,169.2,18,,,percent of total billed charges,pays at 18% of total charges,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658,70,,,percent of total billed charges,70% of total billed charges,705,75,,,percent of total billed charges,75% of total billed charges,470,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,752,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,564,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,940,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,161.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,658,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,564,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,658,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,940,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,940,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.3,940,
FEMORAL COMPONENT,3615389,CDM,278,RC,C1776,HCPCS,Outpatient,,,14460,8676,,2602.8,18,,,percent of total billed charges,pays at 18% of total charges,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2602.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10122,70,,,percent of total billed charges,70% of total billed charges,10845,75,,,percent of total billed charges,75% of total billed charges,7230,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11568,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8676,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14460,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2491.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6507,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10122,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8676,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5494.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10122,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6940.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14460,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14460,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2265.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2265.88,14460,
ACETABULAR CUP/SHELL,3615390,CDM,278,RC,C1776,HCPCS,Outpatient,,,12935,7761,,2328.3,18,,,percent of total billed charges,pays at 18% of total charges,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2328.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9054.5,70,,,percent of total billed charges,70% of total billed charges,9701.25,75,,,percent of total billed charges,75% of total billed charges,6467.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10348,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7761,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12935,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2228.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5820.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9054.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7761,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4915.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9054.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6208.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12935,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12935,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2026.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2026.91,12935,
CATHETER SET RV ASSIST,3615391,CDM,272,RC,,,Outpatient,,,36400,21840,,6552,18,,,percent of total billed charges,pays at 18% of total charges,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6552,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18200,50,,,percent of total billed charges,pays at 50% of total billed charges,25480,70,,,percent of total billed charges,70% of total billed charges,27300,75,,,percent of total billed charges,75% of total billed charges,18200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27846,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16380,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13832,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,25480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17472,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,36400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32760,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5703.88,36400,
KIT CARTILAGE ALLOGRAFT,3615392,CDM,278,RC,C1762,HCPCS,Outpatient,,,6435,3861,,1158.3,18,,,percent of total billed charges,pays at 18% of total charges,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1158.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4504.5,70,,,percent of total billed charges,70% of total billed charges,4826.25,75,,,percent of total billed charges,75% of total billed charges,3217.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3861,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6435,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1108.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2895.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4504.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3861,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2445.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4504.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3088.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6435,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6435,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1008.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.36,6435,
RADIAL HEAD IMPLANT,3615394,CDM,278,RC,C1776,HCPCS,Outpatient,,,2291.9,1375.14,,412.54,18,,,percent of total billed charges,pays at 18% of total charges,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1604.33,70,,,percent of total billed charges,70% of total billed charges,1718.93,75,,,percent of total billed charges,75% of total billed charges,1145.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1833.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1375.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2291.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,394.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1031.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1604.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1375.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,870.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1604.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2291.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2291.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,359.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.14,2291.9,
RADIAL HEAD IMPLANT,3615395,CDM,278,RC,C1776,HCPCS,Outpatient,,,4923.5,2954.1,,886.23,18,,,percent of total billed charges,pays at 18% of total charges,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,886.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3446.45,70,,,percent of total billed charges,70% of total billed charges,3692.63,75,,,percent of total billed charges,75% of total billed charges,2461.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3938.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2954.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4923.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,848.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2215.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3446.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2954.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1870.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3446.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2363.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4923.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4923.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,771.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.51,4923.5,
RADIAL HEAD IMPLANT,3615396,CDM,278,RC,C1776,HCPCS,Outpatient,,,1478.75,887.25,,266.18,18,,,percent of total billed charges,pays at 18% of total charges,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1035.13,70,,,percent of total billed charges,70% of total billed charges,1109.06,75,,,percent of total billed charges,75% of total billed charges,739.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1183,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,887.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1478.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,254.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1035.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,887.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,561.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1035.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1478.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1478.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.72,1478.75,
STAPLE OSTAPLE BONE,3615397,CDM,278,RC,C1713,HCPCS,Outpatient,,,471.5,282.9,,84.87,18,,,percent of total billed charges,pays at 18% of total charges,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.05,70,,,percent of total billed charges,70% of total billed charges,353.63,75,,,percent of total billed charges,75% of total billed charges,235.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,377.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,471.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,330.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,282.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,330.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,471.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,471.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.88,471.5,
MESH CIRCLE SM,3615398,CDM,278,RC,C1781,HCPCS,Outpatient,,,877,526.2,,157.86,18,,,percent of total billed charges,pays at 18% of total charges,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.9,70,,,percent of total billed charges,70% of total billed charges,657.75,75,,,percent of total billed charges,75% of total billed charges,438.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,701.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,877,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,151.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,613.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,526.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,613.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,877,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,877,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.43,877,
CLIP CLOSED TUBE,3615399,CDM,272,RC,,,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105,50,,,percent of total billed charges,pays at 50% of total billed charges,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
CLAMP ADJUSTABLE,3615402,CDM,278,RC,,,Outpatient,,,631,378.6,,113.58,18,,,percent of total billed charges,pays at 18% of total charges,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.5,50,,,percent of total billed charges,pays at 50% of total billed charges,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,315.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,631,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,631,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,631,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,631,
CLAMP UNIV,3615403,CDM,278,RC,C1713,HCPCS,Outpatient,,,996.5,597.9,,179.37,18,,,percent of total billed charges,pays at 18% of total charges,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.55,70,,,percent of total billed charges,70% of total billed charges,747.38,75,,,percent of total billed charges,75% of total billed charges,498.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,797.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,597.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,996.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,171.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,697.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,597.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,697.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,996.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,996.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.15,996.5,
ROD CARBON FIBER,3615404,CDM,272,RC,,,Outpatient,,,490.5,294.3,,88.29,18,,,percent of total billed charges,pays at 18% of total charges,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.25,50,,,percent of total billed charges,pays at 50% of total billed charges,343.35,70,,,percent of total billed charges,70% of total billed charges,367.88,75,,,percent of total billed charges,75% of total billed charges,245.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,392.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,294.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,343.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,343.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,490.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,441.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.86,490.5,
ROD CARBON,3615406,CDM,278,RC,C1713,HCPCS,Outpatient,,,955,573,,171.9,18,,,percent of total billed charges,pays at 18% of total charges,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.5,70,,,percent of total billed charges,70% of total billed charges,716.25,75,,,percent of total billed charges,75% of total billed charges,477.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,764,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,955,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,164.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,668.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,573,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,362.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,668.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,955,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,955,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.65,955,
CAST PADDING SPECIALIST 3 IN,3615416,CDM,272,RC,,,Outpatient,,,6.5,3.9,,1.17,18,,,percent of total billed charges,pays at 18% of total charges,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,6.5,
CAST PADDING SPECIALIST 4 IN,3615417,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CAST PADDING,3615418,CDM,272,RC,,,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
BLADE SAW DUAL,3615429,CDM,272,RC,,,Outpatient,,,153.5,92.1,,27.63,18,,,percent of total billed charges,pays at 18% of total charges,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.75,50,,,percent of total billed charges,pays at 50% of total billed charges,107.45,70,,,percent of total billed charges,70% of total billed charges,115.13,75,,,percent of total billed charges,75% of total billed charges,76.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,107.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,153.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,138.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.05,153.5,
STIMULATOR NEURO,3615433,CDM,278,RC,C1820,HCPCS,Outpatient,,,37435.32,22461.19,,6738.36,18,,,percent of total billed charges,pays at 18% of total charges,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6738.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26204.72,70,,,percent of total billed charges,70% of total billed charges,28076.49,75,,,percent of total billed charges,75% of total billed charges,18717.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29948.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22461.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37435.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6450.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16845.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26204.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22461.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14225.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26204.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17968.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37435.32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37435.32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5866.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5866.11,37435.32,
STIMULATOR NEURO,3615434,CDM,278,RC,C1820,HCPCS,Outpatient,,,29835,17901,,5370.3,18,,,percent of total billed charges,pays at 18% of total charges,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5370.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20884.5,70,,,percent of total billed charges,70% of total billed charges,22376.25,75,,,percent of total billed charges,75% of total billed charges,14917.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23868,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17901,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29835,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5140.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13425.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20884.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17901,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11337.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20884.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14320.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29835,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29835,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4675.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4675.14,29835,
CAST SCOTCHCAST 3 INCH,3615435,CDM,272,RC,,,Outpatient,,,142,85.2,,25.56,18,,,percent of total billed charges,pays at 18% of total charges,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71,50,,,percent of total billed charges,pays at 50% of total billed charges,99.4,70,,,percent of total billed charges,70% of total billed charges,106.5,75,,,percent of total billed charges,75% of total billed charges,71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,99.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,127.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,142,
CAST SCOTCHCAST 4 INCH,3615436,CDM,272,RC,,,Outpatient,,,55.5,33.3,,9.99,18,,,percent of total billed charges,pays at 18% of total charges,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.75,50,,,percent of total billed charges,pays at 50% of total billed charges,38.85,70,,,percent of total billed charges,70% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,27.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,55.5,
CAST SCOTCHCAST 2 INCH,3615437,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
CAST SCOTCHCAST 5 INCH,3615438,CDM,272,RC,,,Outpatient,,,70.5,42.3,,12.69,18,,,percent of total billed charges,pays at 18% of total charges,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.25,50,,,percent of total billed charges,pays at 50% of total billed charges,49.35,70,,,percent of total billed charges,70% of total billed charges,52.88,75,,,percent of total billed charges,75% of total billed charges,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.05,70.5,
PROGRAMMER PATIENT,3615439,CDM,272,RC,,,Outpatient,,,2860,1716,,514.8,18,,,percent of total billed charges,pays at 18% of total charges,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,514.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1430,50,,,percent of total billed charges,pays at 50% of total billed charges,2002,70,,,percent of total billed charges,70% of total billed charges,2145,75,,,percent of total billed charges,75% of total billed charges,1430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2187.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1086.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1372.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2574,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.16,2860,
STAPLE DRIVER BONE ARTHO,3615443,CDM,278,RC,C1713,HCPCS,Outpatient,,,414.35,248.61,,74.58,18,,,percent of total billed charges,pays at 18% of total charges,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.05,70,,,percent of total billed charges,70% of total billed charges,310.76,75,,,percent of total billed charges,75% of total billed charges,207.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,414.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,414.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.93,414.35,
STAPLE TENDON ARTHO,3615444,CDM,278,RC,,,Outpatient,,,414.35,248.61,,74.58,18,,,percent of total billed charges,pays at 18% of total charges,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.18,50,,,percent of total billed charges,pays at 50% of total billed charges,290.05,70,,,percent of total billed charges,70% of total billed charges,310.76,75,,,percent of total billed charges,75% of total billed charges,207.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,414.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,414.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.93,414.35,
SET ARTHO W DISP DEVICE,3615446,CDM,272,RC,,,Outpatient,,,414.35,248.61,,74.58,18,,,percent of total billed charges,pays at 18% of total charges,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.18,50,,,percent of total billed charges,pays at 50% of total billed charges,290.05,70,,,percent of total billed charges,70% of total billed charges,310.76,75,,,percent of total billed charges,75% of total billed charges,207.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,331.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,414.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,372.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.93,414.35,
COLLAGEN SCAFFOLD  ARTHO IMPLANT,3615447,CDM,278,RC,,,Outpatient,,,2822.7,1693.62,,508.09,18,,,percent of total billed charges,pays at 18% of total charges,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,508.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1411.35,50,,,percent of total billed charges,pays at 50% of total billed charges,1975.89,70,,,percent of total billed charges,70% of total billed charges,2117.03,75,,,percent of total billed charges,75% of total billed charges,1411.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2258.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1693.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2822.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1270.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1975.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1693.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1072.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1975.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1354.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2822.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2822.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.32,2822.7,
TISSUE ALLODERM PER SQ CM,3615449,CDM,636,RC,Q4116,HCPCS,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
IMMOBILIZER KNEE,3615454,CDM,274,RC,L1830,HCPCS,Outpatient,,,193,115.8,,276.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,96.5,50,,,percent of total billed charges,pays at 50% of total billed charges,135.1,70,,,percent of total billed charges,70% of total billed charges,144.75,75,,,percent of total billed charges,75% of total billed charges,140.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.74,350,,,Fee Schedule,350% of CMS OPPS Rate,79.77,102,,,Fee Schedule,102% of CMS OPPS Rate,193,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,86.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,73.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,135.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,179.88,230,,,Fee Schedule,230% of CMS OPPS Rate,92.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,100% of CMS OPPS Rate,193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,30.24,276.86,
BLOOD WARMING RANGER DISC,3615460,CDM,272,RC,,,Outpatient,,,59,35.4,,10.62,18,,,percent of total billed charges,pays at 18% of total charges,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.5,50,,,percent of total billed charges,pays at 50% of total billed charges,41.3,70,,,percent of total billed charges,70% of total billed charges,44.25,75,,,percent of total billed charges,75% of total billed charges,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,59,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,59,
TUNNELERS 65 CM DISP,3615462,CDM,272,RC,,,Outpatient,,,131.5,78.9,,23.67,18,,,percent of total billed charges,pays at 18% of total charges,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.75,50,,,percent of total billed charges,pays at 50% of total billed charges,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,65.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,131.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.61,131.5,
SLING ARM,3615473,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
DRIVER HEX SCREW,3615507,CDM,278,RC,,,Outpatient,,,707.5,424.5,,127.35,18,,,percent of total billed charges,pays at 18% of total charges,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.75,50,,,percent of total billed charges,pays at 50% of total billed charges,495.25,70,,,percent of total billed charges,70% of total billed charges,530.63,75,,,percent of total billed charges,75% of total billed charges,353.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,566,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,707.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,495.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,424.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,495.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,707.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,707.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.87,707.5,
DRILL SET QUICKSET,3615509,CDM,272,RC,,,Outpatient,,,577.5,346.5,,103.95,18,,,percent of total billed charges,pays at 18% of total charges,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.75,50,,,percent of total billed charges,pays at 50% of total billed charges,404.25,70,,,percent of total billed charges,70% of total billed charges,433.13,75,,,percent of total billed charges,75% of total billed charges,288.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,462,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,404.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,346.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,404.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,577.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,519.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.49,577.5,
PLATE VOLAR 2 CLMN RADIUS,3615510,CDM,278,RC,C1713,HCPCS,Outpatient,,,1687.5,1012.5,,303.75,18,,,percent of total billed charges,pays at 18% of total charges,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.25,70,,,percent of total billed charges,70% of total billed charges,1265.63,75,,,percent of total billed charges,75% of total billed charges,843.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1350,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1012.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1687.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,290.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1181.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1012.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,641.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1181.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1687.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1687.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.43,1687.5,
OCTOPUS 4,3615512,CDM,272,RC,,,Outpatient,,,1781,1068.6,,320.58,18,,,percent of total billed charges,pays at 18% of total charges,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,890.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1246.7,70,,,percent of total billed charges,70% of total billed charges,1335.75,75,,,percent of total billed charges,75% of total billed charges,890.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1424.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1068.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1362.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1246.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1068.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,676.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1246.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1781,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1602.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.08,1781,
MAGNUM KNOTLESS,3615540,CDM,272,RC,,,Outpatient,,,662.5,397.5,,119.25,18,,,percent of total billed charges,pays at 18% of total charges,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,331.25,50,,,percent of total billed charges,pays at 50% of total billed charges,463.75,70,,,percent of total billed charges,70% of total billed charges,496.88,75,,,percent of total billed charges,75% of total billed charges,331.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,530,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,506.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,596.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.81,662.5,
SMART STITCH,3615541,CDM,278,RC,C1713,HCPCS,Outpatient,,,240,144,,43.2,18,,,percent of total billed charges,pays at 18% of total charges,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,70,,,percent of total billed charges,70% of total billed charges,180,75,,,percent of total billed charges,75% of total billed charges,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.61,240,
SMART STITCH SUTURE KT,3615542,CDM,272,RC,,,Outpatient,,,277,166.2,,49.86,18,,,percent of total billed charges,pays at 18% of total charges,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.5,50,,,percent of total billed charges,pays at 50% of total billed charges,193.9,70,,,percent of total billed charges,70% of total billed charges,207.75,75,,,percent of total billed charges,75% of total billed charges,138.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,193.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,249.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.41,277,
FIBERWIRE SUTURE KIT,3615544,CDM,272,RC,,,Outpatient,,,745.5,447.3,,134.19,18,,,percent of total billed charges,pays at 18% of total charges,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.75,50,,,percent of total billed charges,pays at 50% of total billed charges,521.85,70,,,percent of total billed charges,70% of total billed charges,559.13,75,,,percent of total billed charges,75% of total billed charges,372.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,596.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,447.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,570.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,521.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,447.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,521.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,745.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,670.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.82,745.5,
DEPUY SIGMA SAW BLADE DIS,3615547,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
SPACER CAPSTONE VERTESTACK,3615550,CDM,278,RC,,,Outpatient,,,7881.5,4728.9,,1418.67,18,,,percent of total billed charges,pays at 18% of total charges,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1418.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3940.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5517.05,70,,,percent of total billed charges,70% of total billed charges,5911.13,75,,,percent of total billed charges,75% of total billed charges,3940.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6305.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4728.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7881.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3546.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5517.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4728.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2994.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5517.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3783.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7881.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7881.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1235.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.03,7881.5,
PLATE CLAVICLE,3615557,CDM,278,RC,C1713,HCPCS,Outpatient,,,1196,717.6,,215.28,18,,,percent of total billed charges,pays at 18% of total charges,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.2,70,,,percent of total billed charges,70% of total billed charges,897,75,,,percent of total billed charges,75% of total billed charges,598,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,717.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1196,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,206.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,837.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,717.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,837.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1196,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1196,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.41,1196,
DRIVER QUICK RELEASE,3615558,CDM,272,RC,,,Outpatient,,,109.5,65.7,,19.71,18,,,percent of total billed charges,pays at 18% of total charges,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.75,50,,,percent of total billed charges,pays at 50% of total billed charges,76.65,70,,,percent of total billed charges,70% of total billed charges,82.13,75,,,percent of total billed charges,75% of total billed charges,54.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,76.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,98.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,109.5,
VERSANAIL,3615560,CDM,278,RC,C1713,HCPCS,Outpatient,,,2715.5,1629.3,,488.79,18,,,percent of total billed charges,pays at 18% of total charges,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1900.85,70,,,percent of total billed charges,70% of total billed charges,2036.63,75,,,percent of total billed charges,75% of total billed charges,1357.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2172.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1629.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2715.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,467.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1221.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1900.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1629.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1031.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1900.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1303.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2715.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2715.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,425.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.52,2715.5,
PLATE NEURO SUPPLMNT FIXATION,3615561,CDM,278,RC,C1713,HCPCS,Outpatient,,,10966,6579.6,,1973.88,18,,,percent of total billed charges,pays at 18% of total charges,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1973.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7676.2,70,,,percent of total billed charges,70% of total billed charges,8224.5,75,,,percent of total billed charges,75% of total billed charges,5483,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8772.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6579.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10966,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1889.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4934.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7676.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6579.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4167.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7676.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5263.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10966,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10966,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1718.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1718.37,10966,
PLATE PYRAMID,3615562,CDM,278,RC,C1713,HCPCS,Outpatient,,,7325.5,4395.3,,1318.59,18,,,percent of total billed charges,pays at 18% of total charges,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5127.85,70,,,percent of total billed charges,70% of total billed charges,5494.13,75,,,percent of total billed charges,75% of total billed charges,3662.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5860.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4395.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7325.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1262.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3296.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5127.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4395.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2783.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5127.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3516.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7325.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7325.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.91,7325.5,
PLATE LCKG ATTCHMT,3615563,CDM,278,RC,C1713,HCPCS,Outpatient,,,841,504.6,,151.38,18,,,percent of total billed charges,pays at 18% of total charges,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.7,70,,,percent of total billed charges,70% of total billed charges,630.75,75,,,percent of total billed charges,75% of total billed charges,420.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,504.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,841,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,588.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,504.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,588.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,841,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,841,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.78,841,
DEVICE INTERLAMINAR FUSION,3615564,CDM,278,RC,C1713,HCPCS,Outpatient,,,8060,4836,,1450.8,18,,,percent of total billed charges,pays at 18% of total charges,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1450.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5642,70,,,percent of total billed charges,70% of total billed charges,6045,75,,,percent of total billed charges,75% of total billed charges,4030,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6448,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4836,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8060,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1388.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3627,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5642,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4836,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3062.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5642,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3868.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8060,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8060,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1263,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1263,8060,
PUTTY BONE 10CC,3615565,CDM,278,RC,C9359,HCPCS,Outpatient,,,3180,1908,,572.4,18,,,percent of total billed charges,pays at 18% of total charges,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,572.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1590,50,,,percent of total billed charges,pays at 50% of total billed charges,2226,70,,,percent of total billed charges,70% of total billed charges,2385,75,,,percent of total billed charges,75% of total billed charges,1590,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1908,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3180,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,547.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2226,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1908,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1208.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2226,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1526.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3180,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3180,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.31,3180,
MESH PROCEED 6X6,3615569,CDM,278,RC,C1781,HCPCS,Outpatient,,,670,402,,120.6,18,,,percent of total billed charges,pays at 18% of total charges,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469,70,,,percent of total billed charges,70% of total billed charges,502.5,75,,,percent of total billed charges,75% of total billed charges,335,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,670,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,469,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,469,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,670,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,670,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.99,670,
MESH PROCEED 6X8,3615570,CDM,278,RC,C1781,HCPCS,Outpatient,,,1193,715.8,,214.74,18,,,percent of total billed charges,pays at 18% of total charges,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.1,70,,,percent of total billed charges,70% of total billed charges,894.75,75,,,percent of total billed charges,75% of total billed charges,596.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,954.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,715.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,835.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,715.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,835.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.94,1193,
PACK C-SECTION,3615576,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
SHEATH ACCESS,3615582,CDM,272,RC,,,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.5,50,,,percent of total billed charges,pays at 50% of total billed charges,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
PLATE CONDYLAR 95 DEG,3615584,CDM,278,RC,C1713,HCPCS,Outpatient,,,1564.5,938.7,,281.61,18,,,percent of total billed charges,pays at 18% of total charges,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.15,70,,,percent of total billed charges,70% of total billed charges,1173.38,75,,,percent of total billed charges,75% of total billed charges,782.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1251.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,938.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1564.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,269.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1095.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,938.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1095.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1564.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1564.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.16,1564.5,
SHEATH URETERAL,3615585,CDM,272,RC,,,Outpatient,,,256.95,154.17,,46.25,18,,,percent of total billed charges,pays at 18% of total charges,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.48,50,,,percent of total billed charges,pays at 50% of total billed charges,179.87,70,,,percent of total billed charges,70% of total billed charges,192.71,75,,,percent of total billed charges,75% of total billed charges,128.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,205.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,179.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,256.95,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,231.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.26,256.95,
DRILL 12MM DISP,3615590,CDM,272,RC,,,Outpatient,,,440,264,,79.2,18,,,percent of total billed charges,pays at 18% of total charges,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220,50,,,percent of total billed charges,pays at 50% of total billed charges,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,220,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,336.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,440,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,396,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.95,440,
PLATE WRIST HOOK,3615593,CDM,278,RC,C1713,HCPCS,Outpatient,,,985,591,,177.3,18,,,percent of total billed charges,pays at 18% of total charges,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,689.5,70,,,percent of total billed charges,70% of total billed charges,738.75,75,,,percent of total billed charges,75% of total billed charges,492.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,788,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,591,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,985,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,169.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,689.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,591,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,689.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,985,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,985,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.35,985,
PEG THRD,3615594,CDM,278,RC,C1713,HCPCS,Outpatient,,,134.5,80.7,,24.21,18,,,percent of total billed charges,pays at 18% of total charges,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.15,70,,,percent of total billed charges,70% of total billed charges,100.88,75,,,percent of total billed charges,75% of total billed charges,67.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,134.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.08,134.5,
DRILL BIT,3615595,CDM,272,RC,,,Outpatient,,,220,132,,39.6,18,,,percent of total billed charges,pays at 18% of total charges,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110,50,,,percent of total billed charges,pays at 50% of total billed charges,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,220,
SYS BONE FIXATION SM,3615598,CDM,278,RC,,,Outpatient,,,564,338.4,,101.52,18,,,percent of total billed charges,pays at 18% of total charges,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282,50,,,percent of total billed charges,pays at 50% of total billed charges,394.8,70,,,percent of total billed charges,70% of total billed charges,423,75,,,percent of total billed charges,75% of total billed charges,282,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,451.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,338.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,564,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,394.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,338.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,394.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,564,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,564,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.38,564,
CERVICAL HARNESS,3615601,CDM,272,RC,,,Outpatient,,,77,46.2,,13.86,18,,,percent of total billed charges,pays at 18% of total charges,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.5,50,,,percent of total billed charges,pays at 50% of total billed charges,53.9,70,,,percent of total billed charges,70% of total billed charges,57.75,75,,,percent of total billed charges,75% of total billed charges,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.07,77,
SCREW CANNULATED BONE,3615609,CDM,278,RC,C1713,HCPCS,Outpatient,,,506,303.6,,91.08,18,,,percent of total billed charges,pays at 18% of total charges,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.2,70,,,percent of total billed charges,70% of total billed charges,379.5,75,,,percent of total billed charges,75% of total billed charges,253,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,506,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,506,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.29,506,
SUTURE LASSO,3615610,CDM,272,RC,,,Outpatient,,,315,189,,56.7,18,,,percent of total billed charges,pays at 18% of total charges,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,50,,,percent of total billed charges,pays at 50% of total billed charges,220.5,70,,,percent of total billed charges,70% of total billed charges,236.25,75,,,percent of total billed charges,75% of total billed charges,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,283.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.36,315,
PLATE DVRAX EXT,3615612,CDM,278,RC,C1713,HCPCS,Outpatient,,,1151,690.6,,207.18,18,,,percent of total billed charges,pays at 18% of total charges,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.7,70,,,percent of total billed charges,70% of total billed charges,863.25,75,,,percent of total billed charges,75% of total billed charges,575.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,920.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,690.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1151,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,805.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,690.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,437.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,805.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.36,1151,
PEG THRD,3615613,CDM,278,RC,C1713,HCPCS,Outpatient,,,134.5,80.7,,24.21,18,,,percent of total billed charges,pays at 18% of total charges,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.15,70,,,percent of total billed charges,70% of total billed charges,100.88,75,,,percent of total billed charges,75% of total billed charges,67.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,134.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.08,134.5,
BONE MACHINED CANC,3615614,CDM,278,RC,,,Outpatient,,,1568.5,941.1,,282.33,18,,,percent of total billed charges,pays at 18% of total charges,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,784.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1097.95,70,,,percent of total billed charges,70% of total billed charges,1176.38,75,,,percent of total billed charges,75% of total billed charges,784.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1254.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,941.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1568.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1097.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,941.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1097.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1568.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.78,1568.5,
CATH GROSHONG DUAL,3615620,CDM,272,RC,C1751,HCPCS,Outpatient,,,635.5,381.3,,114.39,18,,,percent of total billed charges,pays at 18% of total charges,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.85,70,,,percent of total billed charges,70% of total billed charges,476.63,75,,,percent of total billed charges,75% of total billed charges,317.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,508.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,444.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,381.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,444.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,635.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,571.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.58,635.5,
LEADS PACING 6492,3615623,CDM,272,RC,,,Outpatient,,,58,34.8,,10.44,18,,,percent of total billed charges,pays at 18% of total charges,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29,50,,,percent of total billed charges,pays at 50% of total billed charges,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,58,
MENISCAL DARTSTICK,3615729,CDM,278,RC,,,Outpatient,,,238.5,143.1,,42.93,18,,,percent of total billed charges,pays at 18% of total charges,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.25,50,,,percent of total billed charges,pays at 50% of total billed charges,166.95,70,,,percent of total billed charges,70% of total billed charges,178.88,75,,,percent of total billed charges,75% of total billed charges,119.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,166.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,238.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,238.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.37,238.5,
SPACER CERVICAL,3615731,CDM,278,RC,C1821,HCPCS,Outpatient,,,3050,1830,,549,18,,,percent of total billed charges,pays at 18% of total charges,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,549,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2135,70,,,percent of total billed charges,70% of total billed charges,2287.5,75,,,percent of total billed charges,75% of total billed charges,1525,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1830,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3050,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,525.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1372.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2135,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1830,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1159,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2135,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3050,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3050,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.94,3050,
PLATE NARROW LCP 4H TO 9H,3615734,CDM,278,RC,C1713,HCPCS,Outpatient,,,680,408,,122.4,18,,,percent of total billed charges,pays at 18% of total charges,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476,70,,,percent of total billed charges,70% of total billed charges,510,75,,,percent of total billed charges,75% of total billed charges,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,680,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,408,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,680,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,680,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,680,
PUMP PAIN INF,3615740,CDM,272,RC,,,Outpatient,,,428.5,257.1,,77.13,18,,,percent of total billed charges,pays at 18% of total charges,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.25,50,,,percent of total billed charges,pays at 50% of total billed charges,299.95,70,,,percent of total billed charges,70% of total billed charges,321.38,75,,,percent of total billed charges,75% of total billed charges,214.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,299.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,428.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,385.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.15,428.5,
PUMP PAIN PROGRAMMABLE,3615741,CDM,278,RC,C2626,HCPCS,Outpatient,,,14040,8424,,2527.2,18,,,percent of total billed charges,pays at 18% of total charges,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2527.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9828,70,,,percent of total billed charges,70% of total billed charges,10530,75,,,percent of total billed charges,75% of total billed charges,7020,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8424,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14040,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2419.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6318,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9828,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8424,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5335.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9828,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6739.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2200.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2200.07,14040,
PUNCH CORNEAL VACUUM,3615751,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
NEEDLE EXPRESS DISP,3615752,CDM,272,RC,,,Outpatient,,,222,133.2,,39.96,18,,,percent of total billed charges,pays at 18% of total charges,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111,50,,,percent of total billed charges,pays at 50% of total billed charges,155.4,70,,,percent of total billed charges,70% of total billed charges,166.5,75,,,percent of total billed charges,75% of total billed charges,111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,222,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,199.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.79,222,
TUBE VENT PE,3615753,CDM,278,RC,,,Outpatient,,,97.5,58.5,,17.55,18,,,percent of total billed charges,pays at 18% of total charges,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.75,50,,,percent of total billed charges,pays at 50% of total billed charges,68.25,70,,,percent of total billed charges,70% of total billed charges,73.13,75,,,percent of total billed charges,75% of total billed charges,48.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,97.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,97.5,
PUNCH CORNEAL VACUUM,3615754,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
NEEDLE SCORPION DISP,3615756,CDM,272,RC,,,Outpatient,,,437,262.2,,78.66,18,,,percent of total billed charges,pays at 18% of total charges,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.5,50,,,percent of total billed charges,pays at 50% of total billed charges,305.9,70,,,percent of total billed charges,70% of total billed charges,327.75,75,,,percent of total billed charges,75% of total billed charges,218.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,305.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,305.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,437,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,393.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.48,437,
SET BRAT PROCEDURE STD,3615757,CDM,272,RC,,,Outpatient,,,275,165,,49.5,18,,,percent of total billed charges,pays at 18% of total charges,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,275,
RESERVOIR BRAT2 FILTERED,3615758,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
SUCTION PERFUSION,3615759,CDM,272,RC,,,Outpatient,,,60,36,,10.8,18,,,percent of total billed charges,pays at 18% of total charges,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30,50,,,percent of total billed charges,pays at 50% of total billed charges,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,60,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,60,
ABLATOR,3615761,CDM,272,RC,,,Outpatient,,,409.5,245.7,,73.71,18,,,percent of total billed charges,pays at 18% of total charges,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.75,50,,,percent of total billed charges,pays at 50% of total billed charges,286.65,70,,,percent of total billed charges,70% of total billed charges,307.13,75,,,percent of total billed charges,75% of total billed charges,204.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,327.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,409.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,368.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.17,409.5,
STAPLER CONTOUR CUTTER,3615762,CDM,272,RC,,,Outpatient,,,650,390,,117,18,,,percent of total billed charges,pays at 18% of total charges,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325,50,,,percent of total billed charges,pays at 50% of total billed charges,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,325,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,497.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,585,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
RELOADS CONTOUR STAPLE,3615763,CDM,272,RC,,,Outpatient,,,731.5,438.9,,131.67,18,,,percent of total billed charges,pays at 18% of total charges,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.75,50,,,percent of total billed charges,pays at 50% of total billed charges,512.05,70,,,percent of total billed charges,70% of total billed charges,548.63,75,,,percent of total billed charges,75% of total billed charges,365.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,585.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,438.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,559.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,512.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,438.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,512.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,731.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,658.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.63,731.5,
CARDIOPLEGIA BRIDGE CONVRSN,3615764,CDM,272,RC,,,Outpatient,,,202.5,121.5,,36.45,18,,,percent of total billed charges,pays at 18% of total charges,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.25,50,,,percent of total billed charges,pays at 50% of total billed charges,141.75,70,,,percent of total billed charges,70% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,101.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,202.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,182.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.73,202.5,
KIT VACCUUM ASST VENOUS DRAINAGE,3615765,CDM,272,RC,,,Outpatient,,,117,70.2,,21.06,18,,,percent of total billed charges,pays at 18% of total charges,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,50,,,percent of total billed charges,pays at 50% of total billed charges,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,117,
PUMPHEAD DISPSBL,3615766,CDM,272,RC,,,Outpatient,,,270,162,,48.6,18,,,percent of total billed charges,pays at 18% of total charges,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,50,,,percent of total billed charges,pays at 50% of total billed charges,189,70,,,percent of total billed charges,70% of total billed charges,202.5,75,,,percent of total billed charges,75% of total billed charges,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,270,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.31,270,
FEMORAL STEM,3615773,CDM,278,RC,C1776,HCPCS,Outpatient,,,450,270,,81,18,,,percent of total billed charges,pays at 18% of total charges,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,450,
FEMORAL STEM,3615774,CDM,278,RC,C1776,HCPCS,Outpatient,,,1194,716.4,,214.92,18,,,percent of total billed charges,pays at 18% of total charges,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.8,70,,,percent of total billed charges,70% of total billed charges,895.5,75,,,percent of total billed charges,75% of total billed charges,597,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,955.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,716.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1194,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,835.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,716.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,835.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1194,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1194,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.1,1194,
FEMORAL STEM,3615776,CDM,278,RC,C1776,HCPCS,Outpatient,,,1326,795.6,,238.68,18,,,percent of total billed charges,pays at 18% of total charges,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,928.2,70,,,percent of total billed charges,70% of total billed charges,994.5,75,,,percent of total billed charges,75% of total billed charges,663,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1326,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,228.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,928.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,928.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1326,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1326,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.78,1326,
RICHARD 11MM INSERT,3615778,CDM,278,RC,,,Outpatient,,,1757.5,1054.5,,316.35,18,,,percent of total billed charges,pays at 18% of total charges,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,878.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1230.25,70,,,percent of total billed charges,70% of total billed charges,1318.13,75,,,percent of total billed charges,75% of total billed charges,878.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1406,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1054.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1757.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,790.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1230.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1054.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,667.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1230.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1757.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1757.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.4,1757.5,
DECANTER BAG,3615790,CDM,272,RC,,,Outpatient,,,6.5,3.9,,1.17,18,,,percent of total billed charges,pays at 18% of total charges,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,6.5,
TRANSDUCER CDX PRESSURE,3615798,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
ELECTRODE EXT BLADE,3615821,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
LINE FOR BLD SETS,3615838,CDM,272,RC,,,Outpatient,,,56,33.6,,10.08,18,,,percent of total billed charges,pays at 18% of total charges,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28,50,,,percent of total billed charges,pays at 50% of total billed charges,39.2,70,,,percent of total billed charges,70% of total billed charges,42,75,,,percent of total billed charges,75% of total billed charges,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.78,56,
BLADE INCISOR,3615841,CDM,272,RC,,,Outpatient,,,164,98.4,,29.52,18,,,percent of total billed charges,pays at 18% of total charges,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,164,
LARGE DISPOSABLE INSERTS,3615843,CDM,272,RC,,,Outpatient,,,96.5,57.9,,17.37,18,,,percent of total billed charges,pays at 18% of total charges,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.25,50,,,percent of total billed charges,pays at 50% of total billed charges,67.55,70,,,percent of total billed charges,70% of total billed charges,72.38,75,,,percent of total billed charges,75% of total billed charges,48.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,96.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,96.5,
INSERTS DISP,3615844,CDM,272,RC,,,Outpatient,,,96.5,57.9,,17.37,18,,,percent of total billed charges,pays at 18% of total charges,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.25,50,,,percent of total billed charges,pays at 50% of total billed charges,67.55,70,,,percent of total billed charges,70% of total billed charges,72.38,75,,,percent of total billed charges,75% of total billed charges,48.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,96.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,96.5,
ZIMMER SURFACE,3615846,CDM,278,RC,,,Outpatient,,,1746,1047.6,,314.28,18,,,percent of total billed charges,pays at 18% of total charges,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,873,50,,,percent of total billed charges,pays at 50% of total billed charges,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,873,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1746,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,663.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1746,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1746,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.6,1746,
MESH DUAL PLUS 10CM X 15C,3615852,CDM,278,RC,C1781,HCPCS,Outpatient,,,877,526.2,,157.86,18,,,percent of total billed charges,pays at 18% of total charges,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.9,70,,,percent of total billed charges,70% of total billed charges,657.75,75,,,percent of total billed charges,75% of total billed charges,438.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,701.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,877,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,151.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,613.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,526.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,613.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,877,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,877,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.43,877,
MESH DUAL PLUS 20CM X 30C,3615856,CDM,278,RC,C1781,HCPCS,Outpatient,,,3066,1839.6,,551.88,18,,,percent of total billed charges,pays at 18% of total charges,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,551.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2146.2,70,,,percent of total billed charges,70% of total billed charges,2299.5,75,,,percent of total billed charges,75% of total billed charges,1533,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2452.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1839.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3066,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,528.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1379.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2146.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1839.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1165.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2146.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1471.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3066,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3066,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.44,3066,
BLADE INCISOR,3615859,CDM,272,RC,,,Outpatient,,,188,112.8,,33.84,18,,,percent of total billed charges,pays at 18% of total charges,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94,50,,,percent of total billed charges,pays at 50% of total billed charges,131.6,70,,,percent of total billed charges,70% of total billed charges,141,75,,,percent of total billed charges,75% of total billed charges,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,188,
SCREW SCHANZ BLUNT  TROCAR,3615867,CDM,278,RC,C1713,HCPCS,Outpatient,,,181.5,108.9,,32.67,18,,,percent of total billed charges,pays at 18% of total charges,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.05,70,,,percent of total billed charges,70% of total billed charges,136.13,75,,,percent of total billed charges,75% of total billed charges,90.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.44,181.5,
BOLT MIDFOOT FUSION,3615876,CDM,278,RC,C1713,HCPCS,Outpatient,,,706,423.6,,127.08,18,,,percent of total billed charges,pays at 18% of total charges,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.2,70,,,percent of total billed charges,70% of total billed charges,529.5,75,,,percent of total billed charges,75% of total billed charges,353,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,423.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,706,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,494.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,423.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,494.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,706,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,706,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.63,706,
STENT SINUS TARSI,3615878,CDM,278,RC,S2117,HCPCS,Outpatient,,,2587,1552.2,,,,,,Other,Not Separately reimbursable,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1293.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1810.9,70,,,percent of total billed charges,70% of total billed charges,1940.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2069.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2587,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,445.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1164.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1810.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1552.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,983.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1810.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1241.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2587,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.38,2587,
PLEGIAGUNED CARDIPLEGIN V,3615882,CDM,278,RC,,,Outpatient,,,55.5,33.3,,,,,,Other,Not Separately reimbursable,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.75,50,,,percent of total billed charges,pays at 50% of total billed charges,38.85,70,,,percent of total billed charges,70% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,55.5,
TUBING PRESSURE,3615886,CDM,272,RC,,,Outpatient,,,13.5,8.1,,,,,,Other,Not Separately reimbursable,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,50,,,percent of total billed charges,pays at 50% of total billed charges,9.45,70,,,percent of total billed charges,70% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,12.15,
ASSY HOSE,3615889,CDM,272,RC,,,Outpatient,,,283.5,170.1,,,,,,Other,Not Separately reimbursable,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,50,,,percent of total billed charges,pays at 50% of total billed charges,198.45,70,,,percent of total billed charges,70% of total billed charges,212.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,255.15,
GRAFT VASCULAR FLEX,3615893,CDM,278,RC,C1768,HCPCS,Outpatient,,,1092,655.2,,,,,,Other,Not Separately reimbursable,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.4,70,,,percent of total billed charges,70% of total billed charges,819,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,188.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,764.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,655.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,764.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1092,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.12,1092,
HEMOCLIP SM,3615894,CDM,272,RC,,,Outpatient,,,3,1.8,,,,,,Other,Not Separately reimbursable,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,2.7,
HEMOCLIP MED,3615895,CDM,272,RC,,,Outpatient,,,48.5,29.1,,,,,,Other,Not Separately reimbursable,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,43.65,
HEMOCLIP LGE,3615896,CDM,272,RC,,,Outpatient,,,8.5,5.1,,,,,,Other,Not Separately reimbursable,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,50,,,percent of total billed charges,pays at 50% of total billed charges,5.95,70,,,percent of total billed charges,70% of total billed charges,6.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,7.65,
BONE CORNERSTONE,3615898,CDM,278,RC,,,Outpatient,,,1557,934.2,,,,,,Other,Not Separately reimbursable,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1089.9,70,,,percent of total billed charges,70% of total billed charges,1167.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1557,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1089.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,934.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,591.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1089.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1557,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.98,1557,
PLATE VOLAR CLMN RADIUS,3615902,CDM,278,RC,C1713,HCPCS,Outpatient,,,1681,1008.6,,,,,,Other,Not Separately reimbursable,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.7,70,,,percent of total billed charges,70% of total billed charges,1260.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1681,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,289.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,638.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1176.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1681,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.41,1681,
CEMENT NOZZLE W OBTURATOR,3615907,CDM,272,RC,,,Outpatient,,,92.5,55.5,,,,,,Other,Not Separately reimbursable,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.25,50,,,percent of total billed charges,pays at 50% of total billed charges,64.75,70,,,percent of total billed charges,70% of total billed charges,69.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,83.25,
CEMENT RESTRICTOR W OBTURATOR,3615908,CDM,278,RC,C1713,HCPCS,Outpatient,,,403,241.8,,,,,,Other,Not Separately reimbursable,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.1,70,,,percent of total billed charges,70% of total billed charges,302.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,322.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,282.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,403,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.15,403,
TUBING STRL 7/8IN X 6FT,3615917,CDM,272,RC,,,Outpatient,,,18,10.8,,,,,,Other,Not Separately reimbursable,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,16.2,
LINER SUCTION,3615926,CDM,272,RC,,,Outpatient,,,12.5,7.5,,,,,,Other,Not Separately reimbursable,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,11.25,
PAINBUSTER 100 ML,3615938,CDM,272,RC,,,Outpatient,,,491.5,294.9,,,,,,Other,Not Separately reimbursable,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.75,50,,,percent of total billed charges,pays at 50% of total billed charges,344.05,70,,,percent of total billed charges,70% of total billed charges,368.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,393.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,344.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,344.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,442.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.02,442.35,
CATH SOAKER PAIN SILVER,3615939,CDM,272,RC,,,Outpatient,,,225,135,,,,,,Other,Not Separately reimbursable,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.5,50,,,percent of total billed charges,pays at 50% of total billed charges,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,202.5,
SUTURE ANCHOR,3615943,CDM,278,RC,C1713,HCPCS,Outpatient,,,589,353.4,,,,,,Other,Not Separately reimbursable,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.3,70,,,percent of total billed charges,70% of total billed charges,441.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,471.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,412.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,412.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.3,589,
PLATE METAPHYSEAL,3615959,CDM,278,RC,C1713,HCPCS,Outpatient,,,1268.5,761.1,,,,,,Other,Not Separately reimbursable,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887.95,70,,,percent of total billed charges,70% of total billed charges,951.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1014.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,218.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,887.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,761.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,482.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,887.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1268.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.77,1268.5,
ACETABULAR CUP/SHELL,3615979,CDM,278,RC,C1776,HCPCS,Outpatient,,,2796,1677.6,,,,,,Other,Not Separately reimbursable,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1957.2,70,,,percent of total billed charges,70% of total billed charges,2097,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,481.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1957.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1677.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1062.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1957.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1342.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2796,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.13,2796,
INTRODUCER PERITONEAL,3615997,CDM,278,RC,C1893,HCPCS,Outpatient,,,72.5,43.5,,,,,,Other,Not Separately reimbursable,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.75,70,,,percent of total billed charges,70% of total billed charges,54.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.36,72.5,
CANNULA VENOUS,3615998,CDM,272,RC,,,Outpatient,,,81,48.6,,,,,,Other,Not Separately reimbursable,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,72.9,
PLATE TIBIAL DIST 6H TO 10H,3616006,CDM,278,RC,C1713,HCPCS,Outpatient,,,1066,639.6,,,,,,Other,Not Separately reimbursable,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.2,70,,,percent of total billed charges,70% of total billed charges,799.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,852.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1066,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,183.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,746.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,746.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1066,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.04,1066,
SCREW,3616013,CDM,278,RC,C1713,HCPCS,Outpatient,,,2156.5,1293.9,,,,,,Other,Not Separately reimbursable,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1509.55,70,,,percent of total billed charges,70% of total billed charges,1617.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1725.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2156.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,371.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1509.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1293.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,819.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1509.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1035.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2156.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,337.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.92,2156.5,
ROD,3616014,CDM,278,RC,,,Outpatient,,,710,426,,,,,,Other,Not Separately reimbursable,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355,50,,,percent of total billed charges,pays at 50% of total billed charges,497,70,,,percent of total billed charges,70% of total billed charges,532.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,568,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,497,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,426,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,497,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,710,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.26,710,
DRILL BIT,3616015,CDM,272,RC,,,Outpatient,,,278.5,167.1,,,,,,Other,Not Separately reimbursable,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.25,50,,,percent of total billed charges,pays at 50% of total billed charges,194.95,70,,,percent of total billed charges,70% of total billed charges,208.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,222.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,250.65,
FEMORAL HEAD,3616017,CDM,278,RC,C1776,HCPCS,Outpatient,,,1580.5,948.3,,,,,,Other,Not Separately reimbursable,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1106.35,70,,,percent of total billed charges,70% of total billed charges,1185.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1264.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,272.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1106.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,948.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,600.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1106.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1580.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.66,1580.5,
FEMORAL STEM,3616018,CDM,278,RC,C1776,HCPCS,Outpatient,,,8515.5,5109.3,,,,,,Other,Not Separately reimbursable,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5960.85,70,,,percent of total billed charges,70% of total billed charges,6386.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6812.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8515.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1467.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3831.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5960.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5109.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3235.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5960.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4087.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8515.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1334.38,8515.5,
ROD CROSSLINK CONNECTOR,3616020,CDM,278,RC,,,Outpatient,,,1800,1080,,,,,,Other,Not Separately reimbursable,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,50,,,percent of total billed charges,pays at 50% of total billed charges,1260,70,,,percent of total billed charges,70% of total billed charges,1350,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,684,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.06,1800,
FEMORAL STEM,3616025,CDM,278,RC,C1776,HCPCS,Outpatient,,,1958.5,1175.1,,,,,,Other,Not Separately reimbursable,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1370.95,70,,,percent of total billed charges,70% of total billed charges,1468.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1566.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1958.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,337.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,881.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1370.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1175.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1370.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,940.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1958.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.9,1958.5,
FEMORAL STEM,3616026,CDM,278,RC,C1776,HCPCS,Outpatient,,,2510.5,1506.3,,,,,,Other,Not Separately reimbursable,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1757.35,70,,,percent of total billed charges,70% of total billed charges,1882.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2008.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2510.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,432.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1129.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1757.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1506.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,953.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1757.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1205.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.4,2510.5,
STEM FEMORAL,3616030,CDM,278,RC,C1776,HCPCS,Outpatient,,,18399.11,11039.47,,,,,,Other,Not Separately reimbursable,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12879.38,70,,,percent of total billed charges,70% of total billed charges,13799.33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,14719.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18399.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3170.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8279.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12879.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11039.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6991.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12879.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8831.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18399.11,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2883.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2883.14,18399.11,
SUTURE VICRYL 3-0,3616036,CDM,272,RC,,,Outpatient,,,38,22.8,,,,,,Other,Not Separately reimbursable,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,34.2,
NAIL PELVIC,3616071,CDM,278,RC,C1713,HCPCS,Outpatient,,,1108,664.8,,,,,,Other,Not Separately reimbursable,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.6,70,,,percent of total billed charges,70% of total billed charges,831,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,886.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,190.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,775.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,664.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,775.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.62,1108,
RETRACTOR ILLUMINATED,3616094,CDM,272,RC,,,Outpatient,,,475,285,,,,,,Other,Not Separately reimbursable,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,50,,,percent of total billed charges,pays at 50% of total billed charges,332.5,70,,,percent of total billed charges,70% of total billed charges,356.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,285,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,332.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,427.5,
TIP-YANKAUER-ORTHO,3616095,CDM,272,RC,,,Outpatient,,,6.5,3.9,,,,,,Other,Not Separately reimbursable,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,5.85,
YANKAEUR ILLUMINATED,3616096,CDM,272,RC,,,Outpatient,,,475,285,,,,,,Other,Not Separately reimbursable,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,50,,,percent of total billed charges,pays at 50% of total billed charges,332.5,70,,,percent of total billed charges,70% of total billed charges,356.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,285,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,332.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.43,427.5,
NEEDLE INCISING,3616101,CDM,272,RC,,,Outpatient,,,53,31.8,,,,,,Other,Not Separately reimbursable,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,50,,,percent of total billed charges,pays at 50% of total billed charges,37.1,70,,,percent of total billed charges,70% of total billed charges,39.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,47.7,
STONEBREAKER PROBE,3616102,CDM,272,RC,,,Outpatient,,,276.75,166.05,,,,,,Other,Not Separately reimbursable,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.38,50,,,percent of total billed charges,pays at 50% of total billed charges,193.73,70,,,percent of total billed charges,70% of total billed charges,207.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,221.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,193.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,249.08,
STONEBREAKER CARTRIDGE,3616104,CDM,272,RC,,,Outpatient,,,29,17.4,,,,,,Other,Not Separately reimbursable,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.5,50,,,percent of total billed charges,pays at 50% of total billed charges,20.3,70,,,percent of total billed charges,70% of total billed charges,21.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,23.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.54,26.1,
CANNULA STAPLER,3616123,CDM,272,RC,,,Outpatient,,,1625,975,,,,,,Other,Not Separately reimbursable,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,812.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1137.5,70,,,percent of total billed charges,70% of total billed charges,1218.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1243.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1462.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,1462.5,
CANNULA,3616124,CDM,272,RC,,,Outpatient,,,181.5,108.9,,,,,,Other,Not Separately reimbursable,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.75,50,,,percent of total billed charges,pays at 50% of total billed charges,127.05,70,,,percent of total billed charges,70% of total billed charges,136.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,145.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.44,163.35,
LACRICATH 2MM,3616126,CDM,278,RC,C1783,HCPCS,Outpatient,,,555.5,333.3,,,,,,Other,Not Separately reimbursable,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.85,70,,,percent of total billed charges,70% of total billed charges,416.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,444.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,388.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,333.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,388.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,555.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.05,555.5,
OBTURATOR STAPLER,3616128,CDM,272,RC,,,Outpatient,,,1014,608.4,,,,,,Other,Not Separately reimbursable,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507,50,,,percent of total billed charges,pays at 50% of total billed charges,709.8,70,,,percent of total billed charges,70% of total billed charges,760.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,811.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,709.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,608.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,709.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,912.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.89,912.6,
LENS SA 60 AT,3616135,CDM,276,RC,C1780,HCPCS,Outpatient,,,359,215.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.3,70,,,percent of total billed charges,70% of total billed charges,269.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,251.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,251.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.42,323.1,
SCREW ANG STABLE LCKG,3616142,CDM,278,RC,C1713,HCPCS,Outpatient,,,396,237.6,,,,,,Other,Not Separately reimbursable,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.2,70,,,percent of total billed charges,70% of total billed charges,297,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,237.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.05,396,
PLATE WRIST STD,3616147,CDM,278,RC,C1713,HCPCS,Outpatient,,,907,544.2,,,,,,Other,Not Separately reimbursable,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,907,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.13,907,
TRAP FINGER DISP,3616153,CDM,272,RC,,,Outpatient,,,61,36.6,,,,,,Other,Not Separately reimbursable,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,54.9,
PENILE PUMP TACTILE,3616159,CDM,278,RC,C1813,HCPCS,Outpatient,,,4420,2652,,,,,,Other,Not Separately reimbursable,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3094,70,,,percent of total billed charges,70% of total billed charges,3315,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3536,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4420,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,761.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1989,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3094,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2652,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1679.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3094,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2121.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4420,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.61,4420,
PENILE RESERVOIR,3616161,CDM,278,RC,C1813,HCPCS,Outpatient,,,2349,1409.4,,,,,,Other,Not Separately reimbursable,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1644.3,70,,,percent of total billed charges,70% of total billed charges,1761.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1879.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2349,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,404.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1644.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1409.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1644.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2349,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.09,2349,
SYS PELVIC SLING,3616162,CDM,278,RC,C1771,HCPCS,Outpatient,,,1458.5,875.1,,,,,,Other,Not Separately reimbursable,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.95,70,,,percent of total billed charges,70% of total billed charges,1093.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1166.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1458.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,251.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1020.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,875.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,554.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1020.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1458.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.55,1458.5,
END CAP,3616165,CDM,278,RC,C1713,HCPCS,Outpatient,,,339,203.4,,,,,,Other,Not Separately reimbursable,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.3,70,,,percent of total billed charges,70% of total billed charges,254.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,271.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,237.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,237.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,339,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.12,339,
SCREW LCKG TI,3616166,CDM,278,RC,C1713,HCPCS,Outpatient,,,275.5,165.3,,,,,,Other,Not Separately reimbursable,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.85,70,,,percent of total billed charges,70% of total billed charges,206.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,220.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.17,275.5,
NAIL TIBIAL,3616167,CDM,278,RC,C1713,HCPCS,Outpatient,,,2850,1710,,,,,,Other,Not Separately reimbursable,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,70,,,percent of total billed charges,70% of total billed charges,2137.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,491.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1282.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1995,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1710,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1995,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.6,2850,
PROLENE MESH SYST EXT,3616168,CDM,278,RC,C1781,HCPCS,Outpatient,,,569,341.4,,,,,,Other,Not Separately reimbursable,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.3,70,,,percent of total billed charges,70% of total billed charges,426.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,455.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,398.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,341.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,398.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,569,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,569,
RADIAL HEAD IMPLANT,3616169,CDM,278,RC,C1776,HCPCS,Outpatient,,,3685,2211,,,,,,Other,Not Separately reimbursable,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2579.5,70,,,percent of total billed charges,70% of total billed charges,2763.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2948,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3685,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,634.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1658.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2579.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2211,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1400.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2579.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1768.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3685,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.44,3685,
TROCAR XCEL BLADLESS DISP,3616171,CDM,272,RC,,,Outpatient,,,92.5,55.5,,,,,,Other,Not Separately reimbursable,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.25,50,,,percent of total billed charges,pays at 50% of total billed charges,64.75,70,,,percent of total billed charges,70% of total billed charges,69.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,83.25,
TROCAR SLEEVE XCEL DISP,3616172,CDM,272,RC,,,Outpatient,,,118.5,71.1,,,,,,Other,Not Separately reimbursable,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.25,50,,,percent of total billed charges,pays at 50% of total billed charges,82.95,70,,,percent of total billed charges,70% of total billed charges,88.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,106.65,
MESH TI DYNAMIC,3616173,CDM,278,RC,C1781,HCPCS,Outpatient,,,2141,1284.6,,,,,,Other,Not Separately reimbursable,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.7,70,,,percent of total billed charges,70% of total billed charges,1605.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1712.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2141,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,368.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1498.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1284.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,813.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1498.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2141,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.49,2141,
SCREW PERIPROSTHETIC,3616175,CDM,278,RC,C1713,HCPCS,Outpatient,,,333.5,200.1,,,,,,Other,Not Separately reimbursable,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.45,70,,,percent of total billed charges,70% of total billed charges,250.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,266.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.26,333.5,
KYPHON HV-R BONE CEMENT,3616176,CDM,278,RC,,,Outpatient,,,318,190.8,,,,,,Other,Not Separately reimbursable,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159,50,,,percent of total billed charges,pays at 50% of total billed charges,222.6,70,,,percent of total billed charges,70% of total billed charges,238.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.83,318,
KYPHON FIRST FRACTURE PAK,3616178,CDM,272,RC,,,Outpatient,,,5666,3399.6,,,,,,Other,Not Separately reimbursable,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2833,50,,,percent of total billed charges,pays at 50% of total billed charges,3966.2,70,,,percent of total billed charges,70% of total billed charges,4249.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4532.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4334.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2549.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3966.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3399.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2153.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3966.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2719.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5099.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887.86,5099.4,
SCREW BONE 1.6,3616179,CDM,278,RC,C1713,HCPCS,Outpatient,,,61,36.6,,,,,,Other,Not Separately reimbursable,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
PLATE STRT,3616180,CDM,278,RC,C1713,HCPCS,Outpatient,,,68.5,41.1,,,,,,Other,Not Separately reimbursable,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
PLATE SHAPED 1.6,3616181,CDM,278,RC,C1713,HCPCS,Outpatient,,,159.5,95.7,,,,,,Other,Not Separately reimbursable,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.65,70,,,percent of total billed charges,70% of total billed charges,119.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,127.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,159.5,
PLATE BURR HOLE,3616182,CDM,278,RC,C1713,HCPCS,Outpatient,,,181.5,108.9,,,,,,Other,Not Separately reimbursable,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.05,70,,,percent of total billed charges,70% of total billed charges,136.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,145.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.44,181.5,
PLATE TMS,3616183,CDM,278,RC,,,Outpatient,,,240.5,144.3,,,,,,Other,Not Separately reimbursable,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.25,50,,,percent of total billed charges,pays at 50% of total billed charges,168.35,70,,,percent of total billed charges,70% of total billed charges,180.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,240.5,
PLATE BURR HOLE COVER,3616184,CDM,278,RC,C1713,HCPCS,Outpatient,,,594.1,356.46,,,,,,Other,Not Separately reimbursable,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.87,70,,,percent of total billed charges,70% of total billed charges,445.58,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,475.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,415.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,415.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.1,594.1,
PLATE PANEL,3616185,CDM,278,RC,C1713,HCPCS,Outpatient,,,748.5,449.1,,,,,,Other,Not Separately reimbursable,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.95,70,,,percent of total billed charges,70% of total billed charges,561.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,598.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,523.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,449.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,523.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,748.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,748.5,
DRILL SCREW,3616187,CDM,278,RC,,,Outpatient,,,127,76.2,,,,,,Other,Not Separately reimbursable,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,50,,,percent of total billed charges,pays at 50% of total billed charges,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,127,
SCREW QUICK TAP,3616188,CDM,278,RC,C1713,HCPCS,Outpatient,,,64,38.4,,,,,,Other,Not Separately reimbursable,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,64,
ANCHOR SUTURE BIOCORKSCREW,3616189,CDM,278,RC,C1713,HCPCS,Outpatient,,,583,349.8,,,,,,Other,Not Separately reimbursable,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.1,70,,,percent of total billed charges,70% of total billed charges,437.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,466.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,583,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,408.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,408.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,583,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.36,583,
NAIL TIBIAL,3616190,CDM,278,RC,C1713,HCPCS,Outpatient,,,1830,1098,,,,,,Other,Not Separately reimbursable,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1281,70,,,percent of total billed charges,70% of total billed charges,1372.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,315.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1281,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1098,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,695.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1281,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1830,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.76,1830,
SYS IMPLANT SHOULDER REPAIR,3616192,CDM,278,RC,C1776,HCPCS,Outpatient,,,2090.4,1254.24,,,,,,Other,Not Separately reimbursable,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1463.28,70,,,percent of total billed charges,70% of total billed charges,1567.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1672.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2090.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,360.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,940.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1463.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1254.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,794.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1463.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2090.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.57,2090.4,
PACK HEMOCONCENTRATION,3616193,CDM,272,RC,,,Outpatient,,,155.5,93.3,,,,,,Other,Not Separately reimbursable,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.75,50,,,percent of total billed charges,pays at 50% of total billed charges,108.85,70,,,percent of total billed charges,70% of total billed charges,116.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,124.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.37,139.95,
GLOBAL HEAD PC,3616194,CDM,278,RC,C1776,HCPCS,Outpatient,,,7615,4569,,,,,,Other,Not Separately reimbursable,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5330.5,70,,,percent of total billed charges,70% of total billed charges,5711.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7615,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1312.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3426.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5330.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4569,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2893.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5330.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3655.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7615,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1193.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.27,7615,
SCREW ENDOFIX HAND INNOVA,3616197,CDM,278,RC,C1713,HCPCS,Outpatient,,,164,98.4,,,,,,Other,Not Separately reimbursable,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,164,
SCREW CAGE,3616204,CDM,278,RC,C1713,HCPCS,Outpatient,,,3712,2227.2,,,,,,Other,Not Separately reimbursable,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2598.4,70,,,percent of total billed charges,70% of total billed charges,2784,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2969.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3712,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,639.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1670.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2598.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2227.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1410.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2598.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1781.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3712,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.67,3712,
CAP HUMERAL,3616205,CDM,278,RC,C1713,HCPCS,Outpatient,,,3731,2238.6,,,,,,Other,Not Separately reimbursable,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2611.7,70,,,percent of total billed charges,70% of total billed charges,2798.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2984.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3731,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,642.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1678.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2611.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2238.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1417.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2611.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1790.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3731,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,584.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.65,3731,
SYS IMPLANT SHOULDER REPAIR,3616206,CDM,278,RC,C1776,HCPCS,Outpatient,,,3250,1950,,,,,,Other,Not Separately reimbursable,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,70,,,percent of total billed charges,70% of total billed charges,2437.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,559.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.28,3250,
LAVAGE WOUND BACTISURE,3616207,CDM,272,RC,,,Outpatient,,,988,592.8,,,,,,Other,Not Separately reimbursable,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494,50,,,percent of total billed charges,pays at 50% of total billed charges,691.6,70,,,percent of total billed charges,70% of total billed charges,741,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,691.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,691.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,889.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.82,889.2,
PLATE ROUND MALLEABLE MESH,3616208,CDM,278,RC,C1713,HCPCS,Outpatient,,,1258,754.8,,,,,,Other,Not Separately reimbursable,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.6,70,,,percent of total billed charges,70% of total billed charges,943.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1006.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,216.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,566.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,880.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,754.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,478.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,880.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1258,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.13,1258,
STONE EXTRACTOR NITINOL,3616209,CDM,272,RC,,,Outpatient,,,396,237.6,,,,,,Other,Not Separately reimbursable,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,50,,,percent of total billed charges,pays at 50% of total billed charges,277.2,70,,,percent of total billed charges,70% of total billed charges,297,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,316.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,237.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,277.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,356.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.05,356.4,
BONE CORTICAL,3616215,CDM,278,RC,C1762,HCPCS,Outpatient,,,1497.5,898.5,,,,,,Other,Not Separately reimbursable,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1048.25,70,,,percent of total billed charges,70% of total billed charges,1123.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1198,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,258.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1048.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,898.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,569.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1048.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1497.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.66,1497.5,
ACETABULAR LINER,3616218,CDM,278,RC,C1713,HCPCS,Outpatient,,,2427.5,1456.5,,,,,,Other,Not Separately reimbursable,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1699.25,70,,,percent of total billed charges,70% of total billed charges,1820.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1942,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2427.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,418.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1699.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1456.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,922.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1699.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1165.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2427.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.39,2427.5,
BONE PSR STRUT,3616223,CDM,278,RC,,,Outpatient,,,4009,2405.4,,,,,,Other,Not Separately reimbursable,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2004.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2806.3,70,,,percent of total billed charges,70% of total billed charges,3006.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4009,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1804.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2806.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2405.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1523.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2806.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1924.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4009,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,628.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.21,4009,
DRILL BIT LGE,3616228,CDM,272,RC,,,Outpatient,,,305.5,183.3,,,,,,Other,Not Separately reimbursable,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.75,50,,,percent of total billed charges,pays at 50% of total billed charges,213.85,70,,,percent of total billed charges,70% of total billed charges,229.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,244.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,213.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,213.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.87,274.95,
GUIDEWIRE THRD,3616230,CDM,272,RC,C1769,HCPCS,Outpatient,,,87.5,52.5,,,,,,Other,Not Separately reimbursable,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,70,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,78.75,
COMP FEMORAL POST SYN,3616232,CDM,278,RC,C1776,HCPCS,Outpatient,,,7063.5,4238.1,,,,,,Other,Not Separately reimbursable,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4944.45,70,,,percent of total billed charges,70% of total billed charges,5297.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5650.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1217.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3178.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4944.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4238.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2684.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4944.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3390.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7063.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1106.85,7063.5,
TUBING PUMP,3616238,CDM,272,RC,,,Outpatient,,,101,60.6,,,,,,Other,Not Separately reimbursable,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.5,50,,,percent of total billed charges,pays at 50% of total billed charges,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,90.9,
TROCAR XCEL BLUNT TIP DIS,3616242,CDM,272,RC,,,Outpatient,,,134.5,80.7,,,,,,Other,Not Separately reimbursable,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.25,50,,,percent of total billed charges,pays at 50% of total billed charges,94.15,70,,,percent of total billed charges,70% of total billed charges,100.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,107.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.08,121.05,
POST TAPER,3616245,CDM,278,RC,,,Outpatient,,,936,561.6,,,,,,Other,Not Separately reimbursable,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,50,,,percent of total billed charges,pays at 50% of total billed charges,655.2,70,,,percent of total billed charges,70% of total billed charges,702,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,655.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,561.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,355.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,655.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.67,936,
FEMORAL STEM FLUTED,3616246,CDM,278,RC,C1713,HCPCS,Outpatient,,,1625,975,,,,,,Other,Not Separately reimbursable,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.5,70,,,percent of total billed charges,70% of total billed charges,1218.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1625,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,279.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,1625,
ALLOGRAFT EPIFIX MESH 4X4.5 PER SQ CM,3616711,CDM,636,RC,Q4131,HCPCS,Outpatient,,,181.22,108.73,,,,,,Other,Not Separately reimbursable,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.61,50,,,percent of total billed charges,pays at 50% of total billed charges,126.85,70,,,percent of total billed charges,70% of total billed charges,135.92,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,126.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.4,163.1,
ALLOGRAFT EPIFIX 2X3MM PER SQ CM,3616712,CDM,636,RC,Q4131,HCPCS,Outpatient,,,247.85,148.71,,,,,,Other,Not Separately reimbursable,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.93,50,,,percent of total billed charges,pays at 50% of total billed charges,173.5,70,,,percent of total billed charges,70% of total billed charges,185.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,198.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.84,223.07,
ALLOGRAFT EPIFIX 4X10MM PER SQ CM,3616713,CDM,636,RC,Q4131,HCPCS,Outpatient,,,139,83.4,,,,,,Other,Not Separately reimbursable,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.5,50,,,percent of total billed charges,pays at 50% of total billed charges,97.3,70,,,percent of total billed charges,70% of total billed charges,104.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,97.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.78,125.1,
ALLOGRAFT EPIFIX 5X18MM PER SQ CM,3616714,CDM,636,RC,Q4131,HCPCS,Outpatient,,,386.88,232.13,,,,,,Other,Not Separately reimbursable,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.44,50,,,percent of total billed charges,pays at 50% of total billed charges,270.82,70,,,percent of total billed charges,70% of total billed charges,290.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,309.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,270.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,270.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.62,348.19,
ALLOGRAFT AMNIOTIC DISC,3616715,CDM,278,RC,V2790,HCPCS,Outpatient,,,617.5,370.5,,,,,,Other,Not Separately reimbursable,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.75,50,,,percent of total billed charges,pays at 50% of total billed charges,432.25,70,,,percent of total billed charges,70% of total billed charges,463.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,494,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,432.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,432.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.76,617.5,
ALLOGRAFT EPIFIX SHEET SM,3616716,CDM,636,RC,Q4131,HCPCS,Outpatient,,,1495,897,,,,,,Other,Not Separately reimbursable,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1046.5,70,,,percent of total billed charges,70% of total billed charges,1121.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1143.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1046.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1046.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1345.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.27,1345.5,
ALLOGRAFT DISC MTP,3616717,CDM,278,RC,C1762,HCPCS,Outpatient,,,3315,1989,,,,,,Other,Not Separately reimbursable,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2320.5,70,,,percent of total billed charges,70% of total billed charges,2486.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3315,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,571.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1491.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2320.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1989,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1259.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2320.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1591.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.46,3315,
ALLOGRAFT AMNIOTIC SHEET LG,3616718,CDM,278,RC,V2790,HCPCS,Outpatient,,,2795,1677,,,,,,Other,Not Separately reimbursable,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1397.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1956.5,70,,,percent of total billed charges,70% of total billed charges,2096.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2795,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,481.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1956.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1677,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1062.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1956.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1341.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2795,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,437.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.98,2795,
AMNIOTIC MEMBRANE WRAP SM,3616719,CDM,278,RC,V2790,HCPCS,Outpatient,,,2915,1749,,,,,,Other,Not Separately reimbursable,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1457.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2040.5,70,,,percent of total billed charges,70% of total billed charges,2186.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2915,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,502.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2040.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1749,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1107.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2040.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1399.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2915,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.78,2915,
AMNIOTIC MEMBRANE WRAP LGE,3616720,CDM,278,RC,V2790,HCPCS,Outpatient,,,3120,1872,,,,,,Other,Not Separately reimbursable,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,50,,,percent of total billed charges,pays at 50% of total billed charges,2184,70,,,percent of total billed charges,70% of total billed charges,2340,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,537.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1872,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1185.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3120,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.9,3120,
AMNIOTIC MEMBRANE WRAP XLG,3616721,CDM,278,RC,V2790,HCPCS,Outpatient,,,6656,3993.6,,1198.08,18,,,percent of total billed charges,pays at 18% of total charges,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1198.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3328,50,,,percent of total billed charges,pays at 50% of total billed charges,4659.2,70,,,percent of total billed charges,70% of total billed charges,4992,75,,,percent of total billed charges,75% of total billed charges,3328,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5324.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3993.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6656,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1146.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2995.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4659.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3993.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2529.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4659.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3194.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6656,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6656,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1043,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1043,6656,
SYRINGE DELIVERY LCKG,3616722,CDM,272,RC,,,Outpatient,,,113,67.8,,20.34,18,,,percent of total billed charges,pays at 18% of total charges,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.5,50,,,percent of total billed charges,pays at 50% of total billed charges,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,56.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,113,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,113,
NDL BONE MARROW ASPIRATE,3616723,CDM,272,RC,,,Outpatient,,,580,348,,104.4,18,,,percent of total billed charges,pays at 18% of total charges,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290,50,,,percent of total billed charges,pays at 50% of total billed charges,406,70,,,percent of total billed charges,70% of total billed charges,435,75,,,percent of total billed charges,75% of total billed charges,290,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,406,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,348,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,406,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,580,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,522,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,580,
ALLOGRAFT ARTHROFLEX PER SQCM,3616724,CDM,278,RC,Q4125,HCPCS,Outpatient,,,183.25,109.95,,32.99,18,,,percent of total billed charges,pays at 18% of total charges,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.63,50,,,percent of total billed charges,pays at 50% of total billed charges,128.28,70,,,percent of total billed charges,70% of total billed charges,137.44,75,,,percent of total billed charges,75% of total billed charges,91.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,183.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.72,183.25,
ALLOGRAFT ARTHROFLEX WASTE PER SQCM,3616725,CDM,278,RC,Q4125,HCPCS,Outpatient,,,183.25,109.95,,32.99,18,,,percent of total billed charges,pays at 18% of total charges,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.63,50,,,percent of total billed charges,pays at 50% of total billed charges,128.28,70,,,percent of total billed charges,70% of total billed charges,137.44,75,,,percent of total billed charges,75% of total billed charges,91.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,183.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.72,183.25,
ALLOGRAFT DISC,3616726,CDM,278,RC,C1762,HCPCS,Outpatient,,,14300,8580,,2574,18,,,percent of total billed charges,pays at 18% of total charges,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2574,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10010,70,,,percent of total billed charges,70% of total billed charges,10725,75,,,percent of total billed charges,75% of total billed charges,7150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8580,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2463.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6435,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10010,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8580,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5434,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10010,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.81,14300,
PLATE HUMERUS,3616970,CDM,278,RC,C1713,HCPCS,Outpatient,,,1949.5,1169.7,,350.91,18,,,percent of total billed charges,pays at 18% of total charges,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,350.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1364.65,70,,,percent of total billed charges,70% of total billed charges,1462.13,75,,,percent of total billed charges,75% of total billed charges,974.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1559.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1169.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1949.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1364.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1169.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,740.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1364.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1949.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1949.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.49,1949.5,
PLATE HUMERUS,3616971,CDM,278,RC,C1713,HCPCS,Outpatient,,,1076,645.6,,193.68,18,,,percent of total billed charges,pays at 18% of total charges,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,753.2,70,,,percent of total billed charges,70% of total billed charges,807,75,,,percent of total billed charges,75% of total billed charges,538,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,860.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1076,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,185.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,753.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,753.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1076,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1076,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.61,1076,
CATH DIALYSIS LONG TERM,3616973,CDM,278,RC,C1750,HCPCS,Outpatient,,,662.5,397.5,,119.25,18,,,percent of total billed charges,pays at 18% of total charges,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.75,70,,,percent of total billed charges,70% of total billed charges,496.88,75,,,percent of total billed charges,75% of total billed charges,331.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,530,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.81,662.5,
SYS SCROTAL RETRACTION,3616974,CDM,272,RC,,,Outpatient,,,390,234,,70.2,18,,,percent of total billed charges,pays at 18% of total charges,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195,50,,,percent of total billed charges,pays at 50% of total billed charges,273,70,,,percent of total billed charges,70% of total billed charges,292.5,75,,,percent of total billed charges,75% of total billed charges,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,298.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,390,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,351,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.11,390,
PUNCH PUSHLOCK DISP,3616975,CDM,272,RC,,,Outpatient,,,149.5,89.7,,26.91,18,,,percent of total billed charges,pays at 18% of total charges,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.75,50,,,percent of total billed charges,pays at 50% of total billed charges,104.65,70,,,percent of total billed charges,70% of total billed charges,112.13,75,,,percent of total billed charges,75% of total billed charges,74.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.43,149.5,
SYSTEM VERTESTACK SPINAL,3616976,CDM,278,RC,,,Outpatient,,,2457,1474.2,,442.26,18,,,percent of total billed charges,pays at 18% of total charges,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1228.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1719.9,70,,,percent of total billed charges,70% of total billed charges,1842.75,75,,,percent of total billed charges,75% of total billed charges,1228.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1965.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1474.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2457,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1105.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1719.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1474.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,933.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1719.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2457,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2457,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.01,2457,
PLATE HUMERAL BASE,3616978,CDM,278,RC,C1713,HCPCS,Outpatient,,,4174,2504.4,,751.32,18,,,percent of total billed charges,pays at 18% of total charges,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,751.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2921.8,70,,,percent of total billed charges,70% of total billed charges,3130.5,75,,,percent of total billed charges,75% of total billed charges,2087,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2504.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4174,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,719.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1878.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2921.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2504.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1586.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2921.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2003.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4174,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4174,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,654.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.07,4174,
STRUT PEEK ALL SIZES,3617000,CDM,278,RC,,,Outpatient,,,4290,2574,,772.2,18,,,percent of total billed charges,pays at 18% of total charges,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2145,50,,,percent of total billed charges,pays at 50% of total billed charges,3003,70,,,percent of total billed charges,70% of total billed charges,3217.5,75,,,percent of total billed charges,75% of total billed charges,2145,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3432,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2574,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4290,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3003,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2574,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1630.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3003,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2059.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4290,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4290,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,672.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.24,4290,
SCREW SLF DRLG,3617004,CDM,278,RC,C1713,HCPCS,Outpatient,,,655,393,,117.9,18,,,percent of total billed charges,pays at 18% of total charges,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.5,70,,,percent of total billed charges,70% of total billed charges,491.25,75,,,percent of total billed charges,75% of total billed charges,327.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,524,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,393,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,655,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,458.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,393,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,458.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,655,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,655,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.64,655,
TIBIAL STEM,3617025,CDM,278,RC,C1776,HCPCS,Outpatient,,,2250,1350,,405,18,,,percent of total billed charges,pays at 18% of total charges,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,70,,,percent of total billed charges,70% of total billed charges,1687.5,75,,,percent of total billed charges,75% of total billed charges,1125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,387.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1575,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1350,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1575,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.58,2250,
TIBIAL STEM,3617026,CDM,278,RC,C1776,HCPCS,Outpatient,,,3697.2,2218.32,,665.5,18,,,percent of total billed charges,pays at 18% of total charges,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,665.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2588.04,70,,,percent of total billed charges,70% of total billed charges,2772.9,75,,,percent of total billed charges,75% of total billed charges,1848.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2957.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2218.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3697.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,637.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1663.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2588.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2218.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1404.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2588.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1774.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3697.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3697.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.35,3697.2,
SCREW,3617028,CDM,278,RC,C1713,HCPCS,Outpatient,,,680.32,408.19,,122.46,18,,,percent of total billed charges,pays at 18% of total charges,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.22,70,,,percent of total billed charges,70% of total billed charges,510.24,75,,,percent of total billed charges,75% of total billed charges,340.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,680.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,476.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,408.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,476.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,680.32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,680.32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.61,680.32,
TOOL DISSECTING AF4,3617054,CDM,272,RC,,,Outpatient,,,377,226.2,,67.86,18,,,percent of total billed charges,pays at 18% of total charges,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.5,50,,,percent of total billed charges,pays at 50% of total billed charges,263.9,70,,,percent of total billed charges,70% of total billed charges,282.75,75,,,percent of total billed charges,75% of total billed charges,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,263.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,377,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,339.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.08,377,
TOOL DISSECTING AF5,3617055,CDM,272,RC,,,Outpatient,,,481,288.6,,86.58,18,,,percent of total billed charges,pays at 18% of total charges,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,50,,,percent of total billed charges,pays at 50% of total billed charges,336.7,70,,,percent of total billed charges,70% of total billed charges,360.75,75,,,percent of total billed charges,75% of total billed charges,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,481,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.37,481,
TOOL DISSECTING AM-2,3617057,CDM,272,RC,,,Outpatient,,,448.5,269.1,,80.73,18,,,percent of total billed charges,pays at 18% of total charges,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.25,50,,,percent of total billed charges,pays at 50% of total billed charges,313.95,70,,,percent of total billed charges,70% of total billed charges,336.38,75,,,percent of total billed charges,75% of total billed charges,224.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,358.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,448.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,403.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,448.5,
TOOL DISSECTING AM-3,3617058,CDM,272,RC,,,Outpatient,,,448.5,269.1,,80.73,18,,,percent of total billed charges,pays at 18% of total charges,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.25,50,,,percent of total billed charges,pays at 50% of total billed charges,313.95,70,,,percent of total billed charges,70% of total billed charges,336.38,75,,,percent of total billed charges,75% of total billed charges,224.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,358.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,448.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,403.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,448.5,
TOOL DISSECTING B-3,3617063,CDM,272,RC,,,Outpatient,,,418,250.8,,75.24,18,,,percent of total billed charges,pays at 18% of total charges,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209,50,,,percent of total billed charges,pays at 50% of total billed charges,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,209,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,376.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,418,
TOOL DISSECTING M-1,3617071,CDM,272,RC,,,Outpatient,,,237.5,142.5,,42.75,18,,,percent of total billed charges,pays at 18% of total charges,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.75,50,,,percent of total billed charges,pays at 50% of total billed charges,166.25,70,,,percent of total billed charges,70% of total billed charges,178.13,75,,,percent of total billed charges,75% of total billed charges,118.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,237.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,213.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,237.5,
COMPONENT CENTRAL BONE FIXATOR,3617128,CDM,272,RC,C1713,HCPCS,Outpatient,,,5448.3,3268.98,,980.69,18,,,percent of total billed charges,pays at 18% of total charges,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,980.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3813.81,70,,,percent of total billed charges,70% of total billed charges,4086.23,75,,,percent of total billed charges,75% of total billed charges,2724.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4358.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3268.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4167.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,938.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2451.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3813.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3268.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2070.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3813.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2615.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5448.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4903.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,853.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.75,5448.3,
COMPONENT DISTAL BONE FIXATOR,3617129,CDM,272,RC,C1713,HCPCS,Outpatient,,,4552.6,2731.56,,819.47,18,,,percent of total billed charges,pays at 18% of total charges,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3186.82,70,,,percent of total billed charges,70% of total billed charges,3414.45,75,,,percent of total billed charges,75% of total billed charges,2276.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3642.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2731.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3482.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,784.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2048.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3186.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2731.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3186.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2185.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4552.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4097.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.39,4552.6,
TROCAR 5MM,3617136,CDM,272,RC,,,Outpatient,,,314,188.4,,56.52,18,,,percent of total billed charges,pays at 18% of total charges,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157,50,,,percent of total billed charges,pays at 50% of total billed charges,219.8,70,,,percent of total billed charges,70% of total billed charges,235.5,75,,,percent of total billed charges,75% of total billed charges,157,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,219.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,219.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,314,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,282.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.2,314,
TROCAR 11MM,3617146,CDM,272,RC,,,Outpatient,,,359,215.4,,64.62,18,,,percent of total billed charges,pays at 18% of total charges,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.5,50,,,percent of total billed charges,pays at 50% of total billed charges,251.3,70,,,percent of total billed charges,70% of total billed charges,269.25,75,,,percent of total billed charges,75% of total billed charges,179.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,251.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,251.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,359,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,323.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.26,359,
CLIP GUN,3617184,CDM,272,RC,,,Outpatient,,,268,160.8,,48.24,18,,,percent of total billed charges,pays at 18% of total charges,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134,50,,,percent of total billed charges,pays at 50% of total billed charges,187.6,70,,,percent of total billed charges,70% of total billed charges,201,75,,,percent of total billed charges,75% of total billed charges,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,187.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,187.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,268,
CLIP GUN RELOAD,3617188,CDM,272,RC,,,Outpatient,,,60,36,,10.8,18,,,percent of total billed charges,pays at 18% of total charges,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30,50,,,percent of total billed charges,pays at 50% of total billed charges,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,60,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,60,
TIBIAL STEM,3617194,CDM,278,RC,C1776,HCPCS,Outpatient,,,1650,990,,297,18,,,percent of total billed charges,pays at 18% of total charges,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,297,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,70,,,percent of total billed charges,70% of total billed charges,1237.5,75,,,percent of total billed charges,75% of total billed charges,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,990,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1650,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,284.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,627,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1155,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,792,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.56,1650,
PFC TIBIAL STEM EXTENSION,3617198,CDM,278,RC,C1776,HCPCS,Outpatient,,,1223.5,734.1,,220.23,18,,,percent of total billed charges,pays at 18% of total charges,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,856.45,70,,,percent of total billed charges,70% of total billed charges,917.63,75,,,percent of total billed charges,75% of total billed charges,611.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,978.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,734.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1223.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,856.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,734.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,464.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,856.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.72,1223.5,
METER URINE,3617321,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
SUCTION POOLE,3617330,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
PAD GROUNDING,3617331,CDM,272,RC,,,Outpatient,,,19,11.4,,3.42,18,,,percent of total billed charges,pays at 18% of total charges,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,19,
MAT INSTRUMENT INST,3617333,CDM,272,RC,,,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
PAD OVAL EYE,3617347,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
SPONGE VAG PACK,3617348,CDM,272,RC,,,Outpatient,,,19,11.4,,3.42,18,,,percent of total billed charges,pays at 18% of total charges,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,19,
CATH OXYGEN,3617350,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
CATH O2,3617351,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
TRAY NERVE BLOCK,3617354,CDM,272,RC,,,Outpatient,,,112.5,67.5,,20.25,18,,,percent of total billed charges,pays at 18% of total charges,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,50,,,percent of total billed charges,pays at 50% of total billed charges,78.75,70,,,percent of total billed charges,70% of total billed charges,84.38,75,,,percent of total billed charges,75% of total billed charges,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,112.5,
SET CONTINUOUS PERIPH NRV BLK CATH,3617355,CDM,272,RC,,,Outpatient,,,66.5,39.9,,11.97,18,,,percent of total billed charges,pays at 18% of total charges,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.25,50,,,percent of total billed charges,pays at 50% of total billed charges,46.55,70,,,percent of total billed charges,70% of total billed charges,49.88,75,,,percent of total billed charges,75% of total billed charges,33.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.42,66.5,
CONNECTOR 5 IN 1,3617356,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
CANNULA AORTIC,3617358,CDM,272,RC,,,Outpatient,,,258.5,155.1,,46.53,18,,,percent of total billed charges,pays at 18% of total charges,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.25,50,,,percent of total billed charges,pays at 50% of total billed charges,180.95,70,,,percent of total billed charges,70% of total billed charges,193.88,75,,,percent of total billed charges,75% of total billed charges,129.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,180.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,258.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,232.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.51,258.5,
TRAY CONTINUOUS NERVE BLOCK PREP,3617359,CDM,272,RC,,,Outpatient,,,61.25,36.75,,11.03,18,,,percent of total billed charges,pays at 18% of total charges,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.63,50,,,percent of total billed charges,pays at 50% of total billed charges,42.88,70,,,percent of total billed charges,70% of total billed charges,45.94,75,,,percent of total billed charges,75% of total billed charges,30.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,61.25,
CATHETER NERVE BLOCK,3617360,CDM,272,RC,,,Outpatient,,,56,33.6,,10.08,18,,,percent of total billed charges,pays at 18% of total charges,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28,50,,,percent of total billed charges,pays at 50% of total billed charges,39.2,70,,,percent of total billed charges,70% of total billed charges,42,75,,,percent of total billed charges,75% of total billed charges,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.78,56,
ENT NAV INSTRUMENT TRACKER,3617361,CDM,272,RC,,,Outpatient,,,234,140.4,,42.12,18,,,percent of total billed charges,pays at 18% of total charges,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,50,,,percent of total billed charges,pays at 50% of total billed charges,163.8,70,,,percent of total billed charges,70% of total billed charges,175.5,75,,,percent of total billed charges,75% of total billed charges,117,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,140.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,163.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,234,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,210.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.67,234,
ENT NAV PATIENT TRACKER,3617363,CDM,272,RC,,,Outpatient,,,285,171,,51.3,18,,,percent of total billed charges,pays at 18% of total charges,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,50,,,percent of total billed charges,pays at 50% of total billed charges,199.5,70,,,percent of total billed charges,70% of total billed charges,213.75,75,,,percent of total billed charges,75% of total billed charges,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,285,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,285,
ENT NAV BLADE TRICUT,3617364,CDM,272,RC,,,Outpatient,,,398.4,239.04,,71.71,18,,,percent of total billed charges,pays at 18% of total charges,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.2,50,,,percent of total billed charges,pays at 50% of total billed charges,278.88,70,,,percent of total billed charges,70% of total billed charges,298.8,75,,,percent of total billed charges,75% of total billed charges,199.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,398.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,358.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.43,398.4,
ENT NAV BLADE RAD,3617366,CDM,272,RC,,,Outpatient,,,398.4,239.04,,71.71,18,,,percent of total billed charges,pays at 18% of total charges,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.2,50,,,percent of total billed charges,pays at 50% of total billed charges,278.88,70,,,percent of total billed charges,70% of total billed charges,298.8,75,,,percent of total billed charges,75% of total billed charges,199.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,398.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,358.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.43,398.4,
HEAD POLYAXIAL SPINAL,3617440,CDM,278,RC,C1713,HCPCS,Outpatient,,,1170,702,,210.6,18,,,percent of total billed charges,pays at 18% of total charges,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819,70,,,percent of total billed charges,70% of total billed charges,877.5,75,,,percent of total billed charges,75% of total billed charges,585,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,936,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,201.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,819,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,702,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,444.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,819,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.34,1170,
SCREW PEDICLE,3617442,CDM,278,RC,C1713,HCPCS,Outpatient,,,714,428.4,,128.52,18,,,percent of total billed charges,pays at 18% of total charges,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,357,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,714,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,271.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,714,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,714,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.88,714,
SCREW PEDICLE,3617443,CDM,278,RC,C1713,HCPCS,Outpatient,,,822,493.2,,147.96,18,,,percent of total billed charges,pays at 18% of total charges,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.4,70,,,percent of total billed charges,70% of total billed charges,616.5,75,,,percent of total billed charges,75% of total billed charges,411,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,657.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,493.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,822,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,575.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,493.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,312.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,575.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,822,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,822,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.81,822,
TIBIAL INSERT,3617446,CDM,278,RC,C1776,HCPCS,Outpatient,,,2526.5,1515.9,,454.77,18,,,percent of total billed charges,pays at 18% of total charges,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1768.55,70,,,percent of total billed charges,70% of total billed charges,1894.88,75,,,percent of total billed charges,75% of total billed charges,1263.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2021.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1515.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2526.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,435.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1768.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1515.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,960.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1768.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2526.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2526.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.9,2526.5,
KIT CRANIAL ACCESS,3617449,CDM,272,RC,,,Outpatient,,,477.5,286.5,,85.95,18,,,percent of total billed charges,pays at 18% of total charges,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.75,50,,,percent of total billed charges,pays at 50% of total billed charges,334.25,70,,,percent of total billed charges,70% of total billed charges,358.13,75,,,percent of total billed charges,75% of total billed charges,238.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,286.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,334.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,286.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,334.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,477.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,429.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.82,477.5,
CANNULA,3617452,CDM,272,RC,,,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44,50,,,percent of total billed charges,pays at 50% of total billed charges,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
KIT QUICKSET CEMENT,3617453,CDM,272,RC,,,Outpatient,,,2860,1716,,514.8,18,,,percent of total billed charges,pays at 18% of total charges,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,514.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1430,50,,,percent of total billed charges,pays at 50% of total billed charges,2002,70,,,percent of total billed charges,70% of total billed charges,2145,75,,,percent of total billed charges,75% of total billed charges,1430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2187.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1086.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1372.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2574,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.16,2860,
SET PIN & GRAFT PASSING,3617458,CDM,272,RC,,,Outpatient,,,550,330,,99,18,,,percent of total billed charges,pays at 18% of total charges,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275,50,,,percent of total billed charges,pays at 50% of total billed charges,385,70,,,percent of total billed charges,70% of total billed charges,412.5,75,,,percent of total billed charges,75% of total billed charges,275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,420.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,495,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.19,550,
HEMOCONCENTCETOR,3617459,CDM,272,RC,,,Outpatient,,,504,302.4,,90.72,18,,,percent of total billed charges,pays at 18% of total charges,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252,50,,,percent of total billed charges,pays at 50% of total billed charges,352.8,70,,,percent of total billed charges,70% of total billed charges,378,75,,,percent of total billed charges,75% of total billed charges,252,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,302.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,352.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,504,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,453.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,504,
KIT MAC INTRODUCER,3617477,CDM,272,RC,C1894,HCPCS,Outpatient,,,189,113.4,,34.02,18,,,percent of total billed charges,pays at 18% of total charges,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,,percent of total billed charges,70% of total billed charges,141.75,75,,,percent of total billed charges,75% of total billed charges,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,189,
KIT ARROW DUAL LUMEN,3617478,CDM,272,RC,C1751,HCPCS,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
DRILL BIT,3617483,CDM,272,RC,,,Outpatient,,,452.5,271.5,,81.45,18,,,percent of total billed charges,pays at 18% of total charges,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.25,50,,,percent of total billed charges,pays at 50% of total billed charges,316.75,70,,,percent of total billed charges,70% of total billed charges,339.38,75,,,percent of total billed charges,75% of total billed charges,226.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,362,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,452.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,452.5,
OSTEOFIL 1 CC,3617489,CDM,278,RC,C1713,HCPCS,Outpatient,,,340,204,,61.2,18,,,percent of total billed charges,pays at 18% of total charges,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
HANDSET DISP,3617494,CDM,272,RC,,,Outpatient,,,877.5,526.5,,157.95,18,,,percent of total billed charges,pays at 18% of total charges,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,438.75,50,,,percent of total billed charges,pays at 50% of total billed charges,614.25,70,,,percent of total billed charges,70% of total billed charges,658.13,75,,,percent of total billed charges,75% of total billed charges,438.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,702,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,671.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,614.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,526.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,614.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,877.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,789.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.5,877.5,
HANDPEICE SET DISP,3617496,CDM,272,RC,,,Outpatient,,,97.5,58.5,,17.55,18,,,percent of total billed charges,pays at 18% of total charges,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.75,50,,,percent of total billed charges,pays at 50% of total billed charges,68.25,70,,,percent of total billed charges,70% of total billed charges,73.13,75,,,percent of total billed charges,75% of total billed charges,48.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,97.5,
TULIE ARMSTRONG ACTIVENT,3617502,CDM,278,RC,,,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
ACETABULAR CUP/SHELL,3617503,CDM,278,RC,C1776,HCPCS,Outpatient,,,691,414.6,,124.38,18,,,percent of total billed charges,pays at 18% of total charges,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.7,70,,,percent of total billed charges,70% of total billed charges,518.25,75,,,percent of total billed charges,75% of total billed charges,345.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,552.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,414.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,691,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,483.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,414.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,483.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,691,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,691,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.28,691,
TUBING STRT SHOT IRR,3617514,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
SHEATH,3617516,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
HARMONIC SCALPEL 14CM,3617536,CDM,272,RC,,,Outpatient,,,391.5,234.9,,70.47,18,,,percent of total billed charges,pays at 18% of total charges,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.75,50,,,percent of total billed charges,pays at 50% of total billed charges,274.05,70,,,percent of total billed charges,70% of total billed charges,293.63,75,,,percent of total billed charges,75% of total billed charges,195.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,313.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,274.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,274.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,391.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,352.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.35,391.5,
BLADE SAW,3617548,CDM,272,RC,,,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
PATELLA BUTTON,3617554,CDM,278,RC,C1776,HCPCS,Outpatient,,,1782.3,1069.38,,320.81,18,,,percent of total billed charges,pays at 18% of total charges,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1247.61,70,,,percent of total billed charges,70% of total billed charges,1336.73,75,,,percent of total billed charges,75% of total billed charges,891.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1425.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1069.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1782.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,307.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1247.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1069.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,677.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1247.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1782.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1782.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.29,1782.3,
TIBIAL TRAY,3617562,CDM,278,RC,C1776,HCPCS,Outpatient,,,7154,4292.4,,1287.72,18,,,percent of total billed charges,pays at 18% of total charges,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1287.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5007.8,70,,,percent of total billed charges,70% of total billed charges,5365.5,75,,,percent of total billed charges,75% of total billed charges,3577,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5723.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4292.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7154,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1232.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5007.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4292.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2718.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5007.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3433.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7154,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7154,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1121.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1121.03,7154,
SUTURE FIBERWIRE,3617579,CDM,272,RC,C1713,HCPCS,Outpatient,,,70.5,42.3,,12.69,18,,,percent of total billed charges,pays at 18% of total charges,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.35,70,,,percent of total billed charges,70% of total billed charges,52.88,75,,,percent of total billed charges,75% of total billed charges,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.05,70.5,
TAPERED SPACER,3617581,CDM,278,RC,C1776,HCPCS,Outpatient,,,380,228,,68.4,18,,,percent of total billed charges,pays at 18% of total charges,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266,70,,,percent of total billed charges,70% of total billed charges,285,75,,,percent of total billed charges,75% of total billed charges,190,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,304,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,266,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,266,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,380,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.55,380,
PLATE DHS BARREL 8H TO 12H,3617597,CDM,278,RC,C1713,HCPCS,Outpatient,,,970,582,,174.6,18,,,percent of total billed charges,pays at 18% of total charges,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,679,70,,,percent of total billed charges,70% of total billed charges,727.5,75,,,percent of total billed charges,75% of total billed charges,485,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,776,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,582,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,970,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,167.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,679,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,582,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,679,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,970,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,970,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152,970,
DEVICE TISSUE SEALER SUPER,3617601,CDM,272,RC,,,Outpatient,,,860,516,,154.8,18,,,percent of total billed charges,pays at 18% of total charges,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,430,50,,,percent of total billed charges,pays at 50% of total billed charges,602,70,,,percent of total billed charges,70% of total billed charges,645,75,,,percent of total billed charges,75% of total billed charges,430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,688,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,602,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,516,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,602,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,774,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.76,860,
BLADE TRICUT,3617604,CDM,272,RC,,,Outpatient,,,425,255,,76.5,18,,,percent of total billed charges,pays at 18% of total charges,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.5,50,,,percent of total billed charges,pays at 50% of total billed charges,297.5,70,,,percent of total billed charges,70% of total billed charges,318.75,75,,,percent of total billed charges,75% of total billed charges,212.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,425,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.6,425,
IMPLANT BIO TRANSFIX,3617606,CDM,278,RC,C1713,HCPCS,Outpatient,,,748.5,449.1,,134.73,18,,,percent of total billed charges,pays at 18% of total charges,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.95,70,,,percent of total billed charges,70% of total billed charges,561.38,75,,,percent of total billed charges,75% of total billed charges,374.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,598.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,449.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,748.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,523.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,449.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,523.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,748.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,748.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,748.5,
TENDON POSTERIOR TIBIALIS,3617610,CDM,278,RC,C1762,HCPCS,Outpatient,,,3210,1926,,577.8,18,,,percent of total billed charges,pays at 18% of total charges,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,70,,,percent of total billed charges,70% of total billed charges,2407.5,75,,,percent of total billed charges,75% of total billed charges,1605,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2568,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1926,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3210,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,553.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2247,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1926,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1219.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2247,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.01,3210,
TENDON SEMITENDINOUS,3617614,CDM,278,RC,C1762,HCPCS,Outpatient,,,3431,2058.6,,617.58,18,,,percent of total billed charges,pays at 18% of total charges,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,617.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2401.7,70,,,percent of total billed charges,70% of total billed charges,2573.25,75,,,percent of total billed charges,75% of total billed charges,1715.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2744.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2058.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3431,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,591.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1543.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2401.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2058.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1303.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2401.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1646.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3431,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3431,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.64,3431,
GUIDEWIRE 3.0,3617624,CDM,272,RC,C1769,HCPCS,Outpatient,,,231,138.6,,41.58,18,,,percent of total billed charges,pays at 18% of total charges,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.25,75,,,percent of total billed charges,75% of total billed charges,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,231,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,207.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.2,231,
SCREW BLADE SPIRAL,3617634,CDM,278,RC,C1713,HCPCS,Outpatient,,,779.5,467.7,,140.31,18,,,percent of total billed charges,pays at 18% of total charges,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.65,70,,,percent of total billed charges,70% of total billed charges,584.63,75,,,percent of total billed charges,75% of total billed charges,389.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,623.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,467.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,779.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,545.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,467.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,545.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,779.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,779.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.15,779.5,
CLAMP LATERAL,3617652,CDM,272,RC,,,Outpatient,,,911.5,546.9,,164.07,18,,,percent of total billed charges,pays at 18% of total charges,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455.75,50,,,percent of total billed charges,pays at 50% of total billed charges,638.05,70,,,percent of total billed charges,70% of total billed charges,683.63,75,,,percent of total billed charges,75% of total billed charges,455.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,729.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,697.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,638.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,546.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,638.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,911.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,820.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.83,911.5,
TAP,3617656,CDM,272,RC,,,Outpatient,,,305.5,183.3,,54.99,18,,,percent of total billed charges,pays at 18% of total charges,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.75,50,,,percent of total billed charges,pays at 50% of total billed charges,213.85,70,,,percent of total billed charges,70% of total billed charges,229.13,75,,,percent of total billed charges,75% of total billed charges,152.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,233.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,213.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,213.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,305.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,274.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.87,305.5,
ACETABULAR LINER,3617659,CDM,278,RC,C1776,HCPCS,Outpatient,,,4550,2730,,819,18,,,percent of total billed charges,pays at 18% of total charges,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3185,70,,,percent of total billed charges,70% of total billed charges,3412.5,75,,,percent of total billed charges,75% of total billed charges,2275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4550,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,783.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.99,4550,
GRAFT VASCULAR,3617668,CDM,278,RC,C1768,HCPCS,Outpatient,,,1384,830.4,,249.12,18,,,percent of total billed charges,pays at 18% of total charges,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,249.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,968.8,70,,,percent of total billed charges,70% of total billed charges,1038,75,,,percent of total billed charges,75% of total billed charges,692,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,830.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1384,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,238.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,968.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,830.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,525.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,968.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,664.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1384,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1384,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.87,1384,
ANCHOR SUTURE BIOSUTURE TAK,3617687,CDM,278,RC,C1713,HCPCS,Outpatient,,,717,430.2,,129.06,18,,,percent of total billed charges,pays at 18% of total charges,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.9,70,,,percent of total billed charges,70% of total billed charges,537.75,75,,,percent of total billed charges,75% of total billed charges,358.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,717,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,717,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,717,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.35,717,
GUIDEPIN,3617688,CDM,272,RC,,,Outpatient,,,253,151.8,,45.54,18,,,percent of total billed charges,pays at 18% of total charges,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.5,50,,,percent of total billed charges,pays at 50% of total billed charges,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,126.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,253,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.65,253,
BONE FILLER 3CC,3617696,CDM,278,RC,C9359,HCPCS,Outpatient,,,1118,670.8,,201.24,18,,,percent of total billed charges,pays at 18% of total charges,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,559,50,,,percent of total billed charges,pays at 50% of total billed charges,782.6,70,,,percent of total billed charges,70% of total billed charges,838.5,75,,,percent of total billed charges,75% of total billed charges,559,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,894.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,670.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1118,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,192.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,782.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,670.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,424.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,782.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1118,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1118,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.19,1118,
BONE FILLER 5CC,3617697,CDM,278,RC,C9359,HCPCS,Outpatient,,,1851,1110.6,,333.18,18,,,percent of total billed charges,pays at 18% of total charges,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,925.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1295.7,70,,,percent of total billed charges,70% of total billed charges,1388.25,75,,,percent of total billed charges,75% of total billed charges,925.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1110.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1851,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,318.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,832.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1295.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1110.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,703.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1295.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1851,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1851,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.05,1851,
BONE VOID FILLER,3617698,CDM,278,RC,C9359,HCPCS,Outpatient,,,4222,2533.2,,759.96,18,,,percent of total billed charges,pays at 18% of total charges,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,759.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2111,50,,,percent of total billed charges,pays at 50% of total billed charges,2955.4,70,,,percent of total billed charges,70% of total billed charges,3166.5,75,,,percent of total billed charges,75% of total billed charges,2111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2533.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4222,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,727.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1899.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2955.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2533.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1604.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2955.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2026.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4222,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4222,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.59,4222,
BONE VOID FILLER,3617699,CDM,278,RC,C9359,HCPCS,Outpatient,,,5548,3328.8,,998.64,18,,,percent of total billed charges,pays at 18% of total charges,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,998.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2774,50,,,percent of total billed charges,pays at 50% of total billed charges,3883.6,70,,,percent of total billed charges,70% of total billed charges,4161,75,,,percent of total billed charges,75% of total billed charges,2774,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4438.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3328.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5548,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,955.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2496.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3883.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3328.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2108.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3883.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2663.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5548,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5548,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,869.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.37,5548,
GUIDEWIRE,3617780,CDM,272,RC,C1769,HCPCS,Outpatient,,,208,124.8,,37.44,18,,,percent of total billed charges,pays at 18% of total charges,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,75,,,percent of total billed charges,75% of total billed charges,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,208,
GUIDEPIN THRD,3617781,CDM,272,RC,,,Outpatient,,,71.5,42.9,,12.87,18,,,percent of total billed charges,pays at 18% of total charges,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.75,50,,,percent of total billed charges,pays at 50% of total billed charges,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,71.5,
PIN FEMORAL CROSS,3617799,CDM,278,RC,C1713,HCPCS,Outpatient,,,466,279.6,,83.88,18,,,percent of total billed charges,pays at 18% of total charges,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.2,70,,,percent of total billed charges,70% of total billed charges,349.5,75,,,percent of total billed charges,75% of total billed charges,233,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,326.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,326.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,466,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,466,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,466,
WRIST SUPPORT ART LINE,3617806,CDM,272,RC,,,Outpatient,,,28.5,17.1,,5.13,18,,,percent of total billed charges,pays at 18% of total charges,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.25,50,,,percent of total billed charges,pays at 50% of total billed charges,19.95,70,,,percent of total billed charges,70% of total billed charges,21.38,75,,,percent of total billed charges,75% of total billed charges,14.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,28.5,
SUCTION IRRIGATOR,3617817,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
ANCHOR SUTURE FASTAK,3617822,CDM,278,RC,C1713,HCPCS,Outpatient,,,335,201,,60.3,18,,,percent of total billed charges,pays at 18% of total charges,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.5,70,,,percent of total billed charges,70% of total billed charges,251.25,75,,,percent of total billed charges,75% of total billed charges,167.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,335,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,234.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,234.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,335,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,335,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.49,335,
SYSTEM MIXING & DELIVERY,3617831,CDM,272,RC,,,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.5,50,,,percent of total billed charges,pays at 50% of total billed charges,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
SCREW CORT,3617833,CDM,278,RC,C1713,HCPCS,Outpatient,,,63.5,38.1,,11.43,18,,,percent of total billed charges,pays at 18% of total charges,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.45,70,,,percent of total billed charges,70% of total billed charges,47.63,75,,,percent of total billed charges,75% of total billed charges,31.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,63.5,
BALLOON & INFLATION BULB,3617844,CDM,272,RC,,,Outpatient,,,446.5,267.9,,80.37,18,,,percent of total billed charges,pays at 18% of total charges,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.25,50,,,percent of total billed charges,pays at 50% of total billed charges,312.55,70,,,percent of total billed charges,70% of total billed charges,334.88,75,,,percent of total billed charges,75% of total billed charges,223.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,357.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,267.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,312.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,446.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,401.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.97,446.5,
BLADE BEAVER,3617846,CDM,272,RC,,,Outpatient,,,67,40.2,,12.06,18,,,percent of total billed charges,pays at 18% of total charges,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,50,,,percent of total billed charges,pays at 50% of total billed charges,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,67,
BLADE BEAVER,3617847,CDM,272,RC,,,Outpatient,,,82,49.2,,14.76,18,,,percent of total billed charges,pays at 18% of total charges,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41,50,,,percent of total billed charges,pays at 50% of total billed charges,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,82,
DRILL BIT,3617862,CDM,272,RC,,,Outpatient,,,138.5,83.1,,24.93,18,,,percent of total billed charges,pays at 18% of total charges,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.25,50,,,percent of total billed charges,pays at 50% of total billed charges,96.95,70,,,percent of total billed charges,70% of total billed charges,103.88,75,,,percent of total billed charges,75% of total billed charges,69.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,138.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,138.5,
HUMERAL STEM,3617866,CDM,278,RC,C1776,HCPCS,Outpatient,,,3853.5,2312.1,,693.63,18,,,percent of total billed charges,pays at 18% of total charges,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,693.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2697.45,70,,,percent of total billed charges,70% of total billed charges,2890.13,75,,,percent of total billed charges,75% of total billed charges,1926.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3082.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2312.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3853.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,663.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2697.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2312.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1464.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2697.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1849.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3853.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3853.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,603.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.84,3853.5,
FEMORAL STEM,3617871,CDM,278,RC,C1776,HCPCS,Outpatient,,,7511.5,4506.9,,1352.07,18,,,percent of total billed charges,pays at 18% of total charges,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5258.05,70,,,percent of total billed charges,70% of total billed charges,5633.63,75,,,percent of total billed charges,75% of total billed charges,3755.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6009.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4506.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7511.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1294.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3380.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5258.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4506.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2854.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5258.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3605.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7511.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7511.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1177.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1177.05,7511.5,
FEMORAL STEM EXTENSION,3617872,CDM,278,RC,C1776,HCPCS,Outpatient,,,4813.58,2888.15,,866.44,18,,,percent of total billed charges,pays at 18% of total charges,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3369.51,70,,,percent of total billed charges,70% of total billed charges,3610.19,75,,,percent of total billed charges,75% of total billed charges,2406.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3850.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2888.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4813.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,829.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2166.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3369.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2888.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1829.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3369.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2310.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4813.58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4813.58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.29,4813.58,
BLADE-BEAVER-7100,3617880,CDM,272,RC,,,Outpatient,,,32.5,19.5,,5.85,18,,,percent of total billed charges,pays at 18% of total charges,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.25,50,,,percent of total billed charges,pays at 50% of total billed charges,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,16.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,32.5,
BLADE BEAVER,3617885,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
PLATE STRT TI,3617888,CDM,278,RC,C1713,HCPCS,Outpatient,,,433.5,260.1,,78.03,18,,,percent of total billed charges,pays at 18% of total charges,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.45,70,,,percent of total billed charges,70% of total billed charges,325.13,75,,,percent of total billed charges,75% of total billed charges,216.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,346.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,433.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,303.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,303.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,433.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,433.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.93,433.5,
PROBE NIM,3617892,CDM,272,RC,,,Outpatient,,,390,234,,70.2,18,,,percent of total billed charges,pays at 18% of total charges,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195,50,,,percent of total billed charges,pays at 50% of total billed charges,273,70,,,percent of total billed charges,70% of total billed charges,292.5,75,,,percent of total billed charges,75% of total billed charges,195,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,298.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,390,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,351,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.11,390,
BLADE UNI,3617904,CDM,272,RC,,,Outpatient,,,177.5,106.5,,31.95,18,,,percent of total billed charges,pays at 18% of total charges,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.75,50,,,percent of total billed charges,pays at 50% of total billed charges,124.25,70,,,percent of total billed charges,70% of total billed charges,133.13,75,,,percent of total billed charges,75% of total billed charges,88.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,177.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,159.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,177.5,
TIBIAL INSERT,3617914,CDM,278,RC,C1776,HCPCS,Outpatient,,,1622.5,973.5,,292.05,18,,,percent of total billed charges,pays at 18% of total charges,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.75,70,,,percent of total billed charges,70% of total billed charges,1216.88,75,,,percent of total billed charges,75% of total billed charges,811.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1298,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,973.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1622.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,279.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1135.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,973.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,616.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1135.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1622.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1622.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.25,1622.5,
GUIDEWIRE,3617918,CDM,272,RC,C1769,HCPCS,Outpatient,,,116.5,69.9,,20.97,18,,,percent of total billed charges,pays at 18% of total charges,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.38,75,,,percent of total billed charges,75% of total billed charges,58.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,116.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,104.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,116.5,
PLATE BROAD 6H TO 11H,3617952,CDM,278,RC,C1713,HCPCS,Outpatient,,,968,580.8,,174.24,18,,,percent of total billed charges,pays at 18% of total charges,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.6,70,,,percent of total billed charges,70% of total billed charges,726,75,,,percent of total billed charges,75% of total billed charges,484,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,774.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,580.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,968,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,166.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,677.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,580.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,677.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,968,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,968,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.69,968,
BLADE SAW GIGLI,3617955,CDM,272,RC,,,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
SCREW 5.5,3617956,CDM,278,RC,C1713,HCPCS,Outpatient,,,3302.5,1981.5,,594.45,18,,,percent of total billed charges,pays at 18% of total charges,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.75,70,,,percent of total billed charges,70% of total billed charges,2476.88,75,,,percent of total billed charges,75% of total billed charges,1651.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2642,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1981.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3302.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,569.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2311.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1981.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1254.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2311.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.5,3302.5,
GUIDEWIRE,3617966,CDM,272,RC,C1769,HCPCS,Outpatient,,,151.5,90.9,,27.27,18,,,percent of total billed charges,pays at 18% of total charges,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.63,75,,,percent of total billed charges,75% of total billed charges,75.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,151.5,
ROD PEEK PERC,3617968,CDM,278,RC,C1713,HCPCS,Outpatient,,,1465.5,879.3,,263.79,18,,,percent of total billed charges,pays at 18% of total charges,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1025.85,70,,,percent of total billed charges,70% of total billed charges,1099.13,75,,,percent of total billed charges,75% of total billed charges,732.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1172.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,879.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1465.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1025.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,879.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,556.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1025.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1465.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1465.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.64,1465.5,
SHEATH INTRAFIX,3617983,CDM,278,RC,C1713,HCPCS,Outpatient,,,383,229.8,,68.94,18,,,percent of total billed charges,pays at 18% of total charges,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.1,70,,,percent of total billed charges,70% of total billed charges,287.25,75,,,percent of total billed charges,75% of total billed charges,191.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,383,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,268.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,229.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,268.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,383,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,383,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.02,383,
SCREW INTRAFIX,3617984,CDM,278,RC,C1713,HCPCS,Outpatient,,,363,217.8,,65.34,18,,,percent of total billed charges,pays at 18% of total charges,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.1,70,,,percent of total billed charges,70% of total billed charges,272.25,75,,,percent of total billed charges,75% of total billed charges,181.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,290.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,363,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,254.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,254.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,363,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,363,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.88,363,
STAPLER SURGICLIP M9.5,3618009,CDM,272,RC,,,Outpatient,,,329.5,197.7,,59.31,18,,,percent of total billed charges,pays at 18% of total charges,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.75,50,,,percent of total billed charges,pays at 50% of total billed charges,230.65,70,,,percent of total billed charges,70% of total billed charges,247.13,75,,,percent of total billed charges,75% of total billed charges,164.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,263.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,230.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,329.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,296.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.63,329.5,
CONNECTORS PLASTIC TUBING,3618014,CDM,272,RC,,,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
SET EXTERNAL DRAINAGE,3618016,CDM,272,RC,,,Outpatient,,,158.5,95.1,,28.53,18,,,percent of total billed charges,pays at 18% of total charges,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.25,50,,,percent of total billed charges,pays at 50% of total billed charges,110.95,70,,,percent of total billed charges,70% of total billed charges,118.88,75,,,percent of total billed charges,75% of total billed charges,79.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,158.5,
STAPLER PURSTRING 45,3618036,CDM,272,RC,,,Outpatient,,,237.5,142.5,,42.75,18,,,percent of total billed charges,pays at 18% of total charges,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.75,50,,,percent of total billed charges,pays at 50% of total billed charges,166.25,70,,,percent of total billed charges,70% of total billed charges,178.13,75,,,percent of total billed charges,75% of total billed charges,118.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,237.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,213.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,237.5,
PLATE DYNAMIC CAULE,3618083,CDM,278,RC,,,Outpatient,,,1489,893.4,,268.02,18,,,percent of total billed charges,pays at 18% of total charges,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1042.3,70,,,percent of total billed charges,70% of total billed charges,1116.75,75,,,percent of total billed charges,75% of total billed charges,744.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,893.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1489,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1042.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,893.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,565.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1042.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1489,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1489,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.33,1489,
CANNULA VISCO EXPRESSION,3618084,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
END CAP O,3618092,CDM,278,RC,C1713,HCPCS,Outpatient,,,259.5,155.7,,46.71,18,,,percent of total billed charges,pays at 18% of total charges,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.65,70,,,percent of total billed charges,70% of total billed charges,194.63,75,,,percent of total billed charges,75% of total billed charges,129.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,181.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,181.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,259.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,259.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.66,259.5,
PATELLA TENDON HEMI,3618104,CDM,278,RC,C1776,HCPCS,Outpatient,,,3906,2343.6,,703.08,18,,,percent of total billed charges,pays at 18% of total charges,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,703.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2734.2,70,,,percent of total billed charges,70% of total billed charges,2929.5,75,,,percent of total billed charges,75% of total billed charges,1953,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2343.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3906,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,673,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1757.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2734.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2343.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1484.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2734.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3906,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3906,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.07,3906,
CEMENT BONE,3618110,CDM,278,RC,C1713,HCPCS,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
PACK LAPAROSCOPY,3618134,CDM,272,RC,,,Outpatient,,,102.88,61.73,,18.52,18,,,percent of total billed charges,pays at 18% of total charges,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.44,50,,,percent of total billed charges,pays at 50% of total billed charges,72.02,70,,,percent of total billed charges,70% of total billed charges,77.16,75,,,percent of total billed charges,75% of total billed charges,51.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102.88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.12,102.88,
SCREW CORT TI,3618140,CDM,278,RC,C1713,HCPCS,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
HANDLE DISTAL,3618141,CDM,272,RC,,,Outpatient,,,384,230.4,,69.12,18,,,percent of total billed charges,pays at 18% of total charges,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192,50,,,percent of total billed charges,pays at 50% of total billed charges,268.8,70,,,percent of total billed charges,70% of total billed charges,288,75,,,percent of total billed charges,75% of total billed charges,192,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,293.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,384,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,345.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.17,384,
SHAVER BLADE MICRO CUTTER,3618142,CDM,272,RC,,,Outpatient,,,1818,1090.8,,327.24,18,,,percent of total billed charges,pays at 18% of total charges,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,909,50,,,percent of total billed charges,pays at 50% of total billed charges,1272.6,70,,,percent of total billed charges,70% of total billed charges,1363.5,75,,,percent of total billed charges,75% of total billed charges,909,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1454.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1090.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1390.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1272.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1090.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,690.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1272.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1818,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1636.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.88,1818,
IMPLANT PROXML INTRPHLNGL FUSION,3618150,CDM,278,RC,C1713,HCPCS,Outpatient,,,1393.6,836.16,,250.85,18,,,percent of total billed charges,pays at 18% of total charges,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.52,70,,,percent of total billed charges,70% of total billed charges,1045.2,75,,,percent of total billed charges,75% of total billed charges,696.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1114.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1393.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,240.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,975.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,836.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,529.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,975.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1393.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1393.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.38,1393.6,
IMPLANT FLEX HNG TOE,3618154,CDM,278,RC,C1776,HCPCS,Outpatient,,,914.5,548.7,,164.61,18,,,percent of total billed charges,pays at 18% of total charges,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.15,70,,,percent of total billed charges,70% of total billed charges,685.88,75,,,percent of total billed charges,75% of total billed charges,457.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,731.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,548.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,914.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,157.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,640.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,548.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,640.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,914.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,914.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.3,914.5,
IMPLANT FLEX HNG TOE,3618157,CDM,278,RC,C1776,HCPCS,Outpatient,,,1143.5,686.1,,205.83,18,,,percent of total billed charges,pays at 18% of total charges,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.45,70,,,percent of total billed charges,70% of total billed charges,857.63,75,,,percent of total billed charges,75% of total billed charges,571.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,914.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,686.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1143.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,197.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,800.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,686.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,800.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1143.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1143.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.19,1143.5,
IMPLANT ARTHRODESIS INTRAMEDULLARY,3618158,CDM,278,RC,C1776,HCPCS,Outpatient,,,836.46,501.88,,150.56,18,,,percent of total billed charges,pays at 18% of total charges,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.52,70,,,percent of total billed charges,70% of total billed charges,627.35,75,,,percent of total billed charges,75% of total billed charges,418.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,669.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,501.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,836.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,585.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,501.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,585.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,836.46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,836.46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.07,836.46,
IMPLANT ARCH MEDIAL,3618159,CDM,278,RC,C1776,HCPCS,Outpatient,,,3309.8,1985.88,,595.76,18,,,percent of total billed charges,pays at 18% of total charges,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,595.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2316.86,70,,,percent of total billed charges,70% of total billed charges,2482.35,75,,,percent of total billed charges,75% of total billed charges,1654.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2647.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1985.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3309.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,570.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1489.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2316.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1985.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1257.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2316.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1588.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3309.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3309.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.65,3309.8,
TUBE ET BRONCHIAL BLOCKER,3618160,CDM,272,RC,,,Outpatient,,,447,268.2,,80.46,18,,,percent of total billed charges,pays at 18% of total charges,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,50,,,percent of total billed charges,pays at 50% of total billed charges,312.9,70,,,percent of total billed charges,70% of total billed charges,335.25,75,,,percent of total billed charges,75% of total billed charges,223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,357.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,312.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,402.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.04,447,
RADIAL HEAD IMPLANT,3618191,CDM,278,RC,C1776,HCPCS,Outpatient,,,3600,2160,,648,18,,,percent of total billed charges,pays at 18% of total charges,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,648,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,70,,,percent of total billed charges,70% of total billed charges,2700,75,,,percent of total billed charges,75% of total billed charges,1800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,620.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1368,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.12,3600,
ACETABULAR LINER,3618229,CDM,278,RC,C1776,HCPCS,Outpatient,,,571,342.6,,102.78,18,,,percent of total billed charges,pays at 18% of total charges,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.7,70,,,percent of total billed charges,70% of total billed charges,428.25,75,,,percent of total billed charges,75% of total billed charges,285.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,456.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,571,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,399.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,399.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,571,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,571,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.48,571,
TISSUE REPLIFORM 2 X 12,3618231,CDM,278,RC,C1763,HCPCS,Outpatient,,,1073,643.8,,193.14,18,,,percent of total billed charges,pays at 18% of total charges,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,751.1,70,,,percent of total billed charges,70% of total billed charges,804.75,75,,,percent of total billed charges,75% of total billed charges,536.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,858.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,643.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1073,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,184.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,751.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,643.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,407.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,751.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1073,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1073,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.14,1073,
CAPIO CL DEVICE,3618232,CDM,272,RC,,,Outpatient,,,1462.5,877.5,,263.25,18,,,percent of total billed charges,pays at 18% of total charges,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,731.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1023.75,70,,,percent of total billed charges,70% of total billed charges,1096.88,75,,,percent of total billed charges,75% of total billed charges,731.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1170,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,877.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1118.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1023.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,877.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,555.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1023.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1462.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1316.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.17,1462.5,
SUTURE CAPIO,3618233,CDM,272,RC,,,Outpatient,,,81,48.6,,14.58,18,,,percent of total billed charges,pays at 18% of total charges,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,81,
TISSUE REPLIFORM 3 X 7,3618235,CDM,278,RC,C1763,HCPCS,Outpatient,,,892.5,535.5,,160.65,18,,,percent of total billed charges,pays at 18% of total charges,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.75,70,,,percent of total billed charges,70% of total billed charges,669.38,75,,,percent of total billed charges,75% of total billed charges,446.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,535.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,153.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,624.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,535.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,339.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,624.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,892.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,892.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.85,892.5,
CAPIO SUTURE,3618237,CDM,278,RC,,,Outpatient,,,50.5,30.3,,9.09,18,,,percent of total billed charges,pays at 18% of total charges,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.25,50,,,percent of total billed charges,pays at 50% of total billed charges,35.35,70,,,percent of total billed charges,70% of total billed charges,37.88,75,,,percent of total billed charges,75% of total billed charges,25.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.91,50.5,
NEEDLE HOLDER,3618242,CDM,272,RC,,,Outpatient,,,119,71.4,,21.42,18,,,percent of total billed charges,pays at 18% of total charges,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.5,50,,,percent of total billed charges,pays at 50% of total billed charges,83.3,70,,,percent of total billed charges,70% of total billed charges,89.25,75,,,percent of total billed charges,75% of total billed charges,59.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,83.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,119,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,119,
PLATE TI 1.5,3618249,CDM,278,RC,C1713,HCPCS,Outpatient,,,223.5,134.1,,40.23,18,,,percent of total billed charges,pays at 18% of total charges,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.45,70,,,percent of total billed charges,70% of total billed charges,167.63,75,,,percent of total billed charges,75% of total billed charges,111.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.02,223.5,
SCREW 1.5,3618252,CDM,278,RC,C1713,HCPCS,Outpatient,,,80,48,,14.4,18,,,percent of total billed charges,pays at 18% of total charges,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
DRILL BIT SM,3618253,CDM,272,RC,,,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.5,50,,,percent of total billed charges,pays at 50% of total billed charges,86.1,70,,,percent of total billed charges,70% of total billed charges,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.27,123,
SCREW CANC 6.0,3618254,CDM,278,RC,C1713,HCPCS,Outpatient,,,278.5,167.1,,50.13,18,,,percent of total billed charges,pays at 18% of total charges,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.95,70,,,percent of total billed charges,70% of total billed charges,208.88,75,,,percent of total billed charges,75% of total billed charges,139.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,278.5,
DERMABOND ADHESIVE,3618259,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
PLATE LCP 4H TO 8H,3618278,CDM,278,RC,C1776,HCPCS,Outpatient,,,510.5,306.3,,91.89,18,,,percent of total billed charges,pays at 18% of total charges,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.35,70,,,percent of total billed charges,70% of total billed charges,382.88,75,,,percent of total billed charges,75% of total billed charges,255.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,510.5,
SCREW LCKG 1.5,3618279,CDM,278,RC,C1713,HCPCS,Outpatient,,,192,115.2,,34.56,18,,,percent of total billed charges,pays at 18% of total charges,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,70,,,percent of total billed charges,70% of total billed charges,144,75,,,percent of total billed charges,75% of total billed charges,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,192,
DRILL BIT 2.8,3618281,CDM,272,RC,,,Outpatient,,,192,115.2,,34.56,18,,,percent of total billed charges,pays at 18% of total charges,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96,50,,,percent of total billed charges,pays at 50% of total billed charges,134.4,70,,,percent of total billed charges,70% of total billed charges,144,75,,,percent of total billed charges,75% of total billed charges,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,172.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,192,
PLATE RECON LCP CVD,3618282,CDM,278,RC,C1713,HCPCS,Outpatient,,,1032,619.2,,185.76,18,,,percent of total billed charges,pays at 18% of total charges,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.4,70,,,percent of total billed charges,70% of total billed charges,774,75,,,percent of total billed charges,75% of total billed charges,516,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,825.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,619.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1032,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,722.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,619.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,722.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1032,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1032,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.71,1032,
SCREW LCKG 3.5,3618283,CDM,278,RC,C1713,HCPCS,Outpatient,,,228.5,137.1,,41.13,18,,,percent of total billed charges,pays at 18% of total charges,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.95,70,,,percent of total billed charges,70% of total billed charges,171.38,75,,,percent of total billed charges,75% of total billed charges,114.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,228.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.81,228.5,
SCREW CORT 2.0,3618284,CDM,278,RC,C1713,HCPCS,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
SCREW LCKG 2.7,3618286,CDM,278,RC,C1713,HCPCS,Outpatient,,,240.5,144.3,,43.29,18,,,percent of total billed charges,pays at 18% of total charges,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.35,70,,,percent of total billed charges,70% of total billed charges,180.38,75,,,percent of total billed charges,75% of total billed charges,120.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,240.5,
TIBIAL TRAY,3618289,CDM,278,RC,C1776,HCPCS,Outpatient,,,4309,2585.4,,775.62,18,,,percent of total billed charges,pays at 18% of total charges,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,775.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3016.3,70,,,percent of total billed charges,70% of total billed charges,3231.75,75,,,percent of total billed charges,75% of total billed charges,2154.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3447.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2585.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4309,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,742.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1939.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3016.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2585.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1637.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3016.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2068.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4309,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4309,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.22,4309,
TIBIAL TRAY,3618290,CDM,278,RC,C1776,HCPCS,Outpatient,,,10850,6510,,1953,18,,,percent of total billed charges,pays at 18% of total charges,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1953,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7595,70,,,percent of total billed charges,70% of total billed charges,8137.5,75,,,percent of total billed charges,75% of total billed charges,5425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1869.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4882.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7595,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4123,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7595,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5208,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1700.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1700.2,10850,
SUTURE LASSO,3618291,CDM,272,RC,,,Outpatient,,,405.5,243.3,,72.99,18,,,percent of total billed charges,pays at 18% of total charges,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.75,50,,,percent of total billed charges,pays at 50% of total billed charges,283.85,70,,,percent of total billed charges,70% of total billed charges,304.13,75,,,percent of total billed charges,75% of total billed charges,202.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,283.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.54,405.5,
CEMENT BONE ANTIBIOTIC,3618292,CDM,278,RC,C1713,HCPCS,Outpatient,,,429,257.4,,77.22,18,,,percent of total billed charges,pays at 18% of total charges,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.3,70,,,percent of total billed charges,70% of total billed charges,321.75,75,,,percent of total billed charges,75% of total billed charges,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,300.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,300.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.22,429,
CABLE CUTTING EDGE,3618293,CDM,272,RC,,,Outpatient,,,216.5,129.9,,38.97,18,,,percent of total billed charges,pays at 18% of total charges,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.25,50,,,percent of total billed charges,pays at 50% of total billed charges,151.55,70,,,percent of total billed charges,70% of total billed charges,162.38,75,,,percent of total billed charges,75% of total billed charges,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,216.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,194.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.93,216.5,
CABLE CUTTING EDGE W/CMP,3618294,CDM,278,RC,,,Outpatient,,,926.25,555.75,,166.73,18,,,percent of total billed charges,pays at 18% of total charges,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.13,50,,,percent of total billed charges,pays at 50% of total billed charges,648.38,70,,,percent of total billed charges,70% of total billed charges,694.69,75,,,percent of total billed charges,75% of total billed charges,463.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,741,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,926.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,648.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,555.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,648.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,926.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.14,926.25,
PLATE 3 LEVEL,3618297,CDM,278,RC,C1713,HCPCS,Outpatient,,,2422.5,1453.5,,436.05,18,,,percent of total billed charges,pays at 18% of total charges,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1695.75,70,,,percent of total billed charges,70% of total billed charges,1816.88,75,,,percent of total billed charges,75% of total billed charges,1211.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1938,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1453.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2422.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,417.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1695.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1453.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,920.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1695.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2422.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2422.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.61,2422.5,
ANCHOR SUTURE SWIVELOCK SUTURE,3618299,CDM,278,RC,C1713,HCPCS,Outpatient,,,688,412.8,,123.84,18,,,percent of total billed charges,pays at 18% of total charges,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.6,70,,,percent of total billed charges,70% of total billed charges,516,75,,,percent of total billed charges,75% of total billed charges,344,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,688,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,481.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,481.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,688,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,688,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.81,688,
MESH COMPOSIX,3618319,CDM,278,RC,C1781,HCPCS,Outpatient,,,1634,980.4,,294.12,18,,,percent of total billed charges,pays at 18% of total charges,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1143.8,70,,,percent of total billed charges,70% of total billed charges,1225.5,75,,,percent of total billed charges,75% of total billed charges,817,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1307.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,980.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1634,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,281.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1143.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,980.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,620.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1143.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1634,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1634,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.05,1634,
SCREW PEEK SET,3618327,CDM,278,RC,C1713,HCPCS,Outpatient,,,439,263.4,,79.02,18,,,percent of total billed charges,pays at 18% of total charges,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.3,70,,,percent of total billed charges,70% of total billed charges,329.25,75,,,percent of total billed charges,75% of total billed charges,219.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,439,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,307.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,263.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,307.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,439,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.79,439,
SCREW SEXTANT PEEK,3618328,CDM,278,RC,C1713,HCPCS,Outpatient,,,3591.5,2154.9,,646.47,18,,,percent of total billed charges,pays at 18% of total charges,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,646.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2514.05,70,,,percent of total billed charges,70% of total billed charges,2693.63,75,,,percent of total billed charges,75% of total billed charges,1795.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2873.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2154.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3591.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,618.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1616.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2514.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2154.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1364.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2514.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1723.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3591.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3591.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,562.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.79,3591.5,
ROD PEEK SEXTANT,3618329,CDM,278,RC,C1713,HCPCS,Outpatient,,,1271,762.6,,228.78,18,,,percent of total billed charges,pays at 18% of total charges,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.7,70,,,percent of total billed charges,70% of total billed charges,953.25,75,,,percent of total billed charges,75% of total billed charges,635.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1016.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,762.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1271,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,218.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,889.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,762.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,482.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,889.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1271,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1271,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.17,1271,
DILATOR LG DISP,3618331,CDM,272,RC,,,Outpatient,,,421,252.6,,75.78,18,,,percent of total billed charges,pays at 18% of total charges,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.5,50,,,percent of total billed charges,pays at 50% of total billed charges,294.7,70,,,percent of total billed charges,70% of total billed charges,315.75,75,,,percent of total billed charges,75% of total billed charges,210.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,336.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,294.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,252.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,294.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,421,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,378.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.97,421,
DILATOR SPINAL SEXTANT,3618332,CDM,272,RC,,,Outpatient,,,1547,928.2,,278.46,18,,,percent of total billed charges,pays at 18% of total charges,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,773.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1082.9,70,,,percent of total billed charges,70% of total billed charges,1160.25,75,,,percent of total billed charges,75% of total billed charges,773.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1237.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1183.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1082.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,928.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,587.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1082.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1547,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1392.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.41,1547,
GLENOID ANCHOR PEG XLINK,3618338,CDM,278,RC,C1713,HCPCS,Outpatient,,,2759.5,1655.7,,496.71,18,,,percent of total billed charges,pays at 18% of total charges,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,496.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1931.65,70,,,percent of total billed charges,70% of total billed charges,2069.63,75,,,percent of total billed charges,75% of total billed charges,1379.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2207.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1655.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2759.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,475.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1241.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1931.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1655.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1048.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1931.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2759.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2759.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.41,2759.5,
IMPLANT BREAST,3618343,CDM,278,RC,,,Outpatient,,,2073.5,1244.1,,373.23,18,,,percent of total billed charges,pays at 18% of total charges,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1036.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1451.45,70,,,percent of total billed charges,70% of total billed charges,1555.13,75,,,percent of total billed charges,75% of total billed charges,1036.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1658.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1244.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2073.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,933.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1451.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1244.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1451.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,995.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2073.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2073.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.92,2073.5,
GLENOID HEAD,3618418,CDM,278,RC,C1776,HCPCS,Outpatient,,,2100,1260,,378,18,,,percent of total billed charges,pays at 18% of total charges,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,378,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2100,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,798,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.07,2100,
HUMERAL STEM,3618419,CDM,278,RC,C1776,HCPCS,Outpatient,,,8729.5,5237.7,,1571.31,18,,,percent of total billed charges,pays at 18% of total charges,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1571.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6110.65,70,,,percent of total billed charges,70% of total billed charges,6547.13,75,,,percent of total billed charges,75% of total billed charges,4364.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6983.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5237.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8729.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1504.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3928.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6110.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5237.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3317.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6110.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4190.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8729.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8729.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1367.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1367.91,8729.5,
VEIN HUMAN,3618420,CDM,278,RC,C1762,HCPCS,Outpatient,,,13579,8147.4,,2444.22,18,,,percent of total billed charges,pays at 18% of total charges,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9505.3,70,,,percent of total billed charges,70% of total billed charges,10184.25,75,,,percent of total billed charges,75% of total billed charges,6789.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10863.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8147.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13579,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2339.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6110.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9505.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8147.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5160.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9505.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6517.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13579,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13579,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2127.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2127.83,13579,
POUCH DEVICE EXT,3618421,CDM,272,RC,,,Outpatient,,,113,67.8,,20.34,18,,,percent of total billed charges,pays at 18% of total charges,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.5,50,,,percent of total billed charges,pays at 50% of total billed charges,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,56.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,113,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.71,113,
PLATE TIBIAL PROX,3618422,CDM,278,RC,C1713,HCPCS,Outpatient,,,1981,1188.6,,356.58,18,,,percent of total billed charges,pays at 18% of total charges,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386.7,70,,,percent of total billed charges,70% of total billed charges,1485.75,75,,,percent of total billed charges,75% of total billed charges,990.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1584.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1188.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1981,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,891.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1386.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1188.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,752.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1386.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1981,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1981,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.42,1981,
GUIDEWIRE 2.5,3618423,CDM,272,RC,C1769,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.27,123,
KIT INSTRUMENT DISP,3618425,CDM,272,RC,,,Outpatient,,,1918,1150.8,,345.24,18,,,percent of total billed charges,pays at 18% of total charges,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,959,50,,,percent of total billed charges,pays at 50% of total billed charges,1342.6,70,,,percent of total billed charges,70% of total billed charges,1438.5,75,,,percent of total billed charges,75% of total billed charges,959,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1534.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1150.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1467.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1342.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1150.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,728.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1342.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,920.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1918,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1726.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.55,1918,
IMPLANT TISSUE FIXATION,3618426,CDM,278,RC,C1713,HCPCS,Outpatient,,,1021,612.6,,183.78,18,,,percent of total billed charges,pays at 18% of total charges,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.7,70,,,percent of total billed charges,70% of total billed charges,765.75,75,,,percent of total billed charges,75% of total billed charges,510.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,816.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,612.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1021,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,175.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,714.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,612.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,714.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1021,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1021,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.99,1021,
SCREW LCKG 5.0,3618427,CDM,278,RC,C1713,HCPCS,Outpatient,,,240.5,144.3,,43.29,18,,,percent of total billed charges,pays at 18% of total charges,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.35,70,,,percent of total billed charges,70% of total billed charges,180.38,75,,,percent of total billed charges,75% of total billed charges,120.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,240.5,
GASTROSTOMY TUBE,3618429,CDM,272,RC,,,Outpatient,,,544,326.4,,97.92,18,,,percent of total billed charges,pays at 18% of total charges,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272,50,,,percent of total billed charges,pays at 50% of total billed charges,380.8,70,,,percent of total billed charges,70% of total billed charges,408,75,,,percent of total billed charges,75% of total billed charges,272,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,380.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,380.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.24,544,
DURAGEN DURAL GRAF 1X3,3618430,CDM,278,RC,C1762,HCPCS,Outpatient,,,902.2,541.32,,162.4,18,,,percent of total billed charges,pays at 18% of total charges,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.54,70,,,percent of total billed charges,70% of total billed charges,676.65,75,,,percent of total billed charges,75% of total billed charges,451.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,721.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,541.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,902.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,631.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,541.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,631.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,902.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,902.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.37,902.2,
DURAGEN DURAL GRAFT,3618431,CDM,278,RC,C1762,HCPCS,Outpatient,,,1740,1044,,313.2,18,,,percent of total billed charges,pays at 18% of total charges,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218,70,,,percent of total billed charges,70% of total billed charges,1305,75,,,percent of total billed charges,75% of total billed charges,870,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1044,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1740,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,299.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1218,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1044,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,661.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1218,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1740,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1740,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.66,1740,
DURASEAL,3618433,CDM,272,RC,,,Outpatient,,,1705,1023,,306.9,18,,,percent of total billed charges,pays at 18% of total charges,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1193.5,70,,,percent of total billed charges,70% of total billed charges,1278.75,75,,,percent of total billed charges,75% of total billed charges,852.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1023,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1304.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1193.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1023,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,647.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1193.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1705,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1534.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.17,1705,
SPACER CERVICAL,3618441,CDM,278,RC,C1821,HCPCS,Outpatient,,,1652.5,991.5,,297.45,18,,,percent of total billed charges,pays at 18% of total charges,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,297.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.75,70,,,percent of total billed charges,70% of total billed charges,1239.38,75,,,percent of total billed charges,75% of total billed charges,826.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1322,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,991.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1652.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,284.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1156.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,991.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,627.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1156.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1652.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1652.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.95,1652.5,
SPACER CERVICAL,3618445,CDM,278,RC,C1821,HCPCS,Outpatient,,,1917.5,1150.5,,345.15,18,,,percent of total billed charges,pays at 18% of total charges,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1342.25,70,,,percent of total billed charges,70% of total billed charges,1438.13,75,,,percent of total billed charges,75% of total billed charges,958.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1534,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1150.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1917.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,330.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,862.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1342.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1150.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,728.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1342.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,920.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1917.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1917.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,300.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.47,1917.5,
SCREW BIOCOMPOSITE TAPERED,3618466,CDM,278,RC,C1713,HCPCS,Outpatient,,,704.5,422.7,,126.81,18,,,percent of total billed charges,pays at 18% of total charges,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.15,70,,,percent of total billed charges,70% of total billed charges,528.38,75,,,percent of total billed charges,75% of total billed charges,352.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,563.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,422.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,704.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,493.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,422.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,493.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,704.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,704.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.4,704.5,
ELECTRODE BALL,3618468,CDM,272,RC,,,Outpatient,,,521,312.6,,93.78,18,,,percent of total billed charges,pays at 18% of total charges,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.5,50,,,percent of total billed charges,pays at 50% of total billed charges,364.7,70,,,percent of total billed charges,70% of total billed charges,390.75,75,,,percent of total billed charges,75% of total billed charges,260.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,398.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,521,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,468.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.64,521,
TENDON POSTERIOR TIBIALIS,3618514,CDM,278,RC,C1762,HCPCS,Outpatient,,,2325,1395,,418.5,18,,,percent of total billed charges,pays at 18% of total charges,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,70,,,percent of total billed charges,70% of total billed charges,1743.75,75,,,percent of total billed charges,75% of total billed charges,1162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1395,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2325,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,400.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1627.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1395,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,883.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1627.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.33,2325,
ROBOT FLAT MARKERS,3618517,CDM,272,RC,,,Outpatient,,,31.6,18.96,,5.69,18,,,percent of total billed charges,pays at 18% of total charges,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.8,50,,,percent of total billed charges,pays at 50% of total billed charges,22.12,70,,,percent of total billed charges,70% of total billed charges,23.7,75,,,percent of total billed charges,75% of total billed charges,15.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,31.6,
ROBOT IRRIGATION TUBE,3618518,CDM,272,RC,,,Outpatient,,,72.8,43.68,,13.1,18,,,percent of total billed charges,pays at 18% of total charges,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.4,50,,,percent of total billed charges,pays at 50% of total billed charges,50.96,70,,,percent of total billed charges,70% of total billed charges,54.6,75,,,percent of total billed charges,75% of total billed charges,36.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.41,72.8,
STRATA VALVE ASSEMBLY,3618519,CDM,278,RC,C1889,HCPCS,Outpatient,,,7335,4401,,1320.3,18,,,percent of total billed charges,pays at 18% of total charges,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1320.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5134.5,70,,,percent of total billed charges,70% of total billed charges,5501.25,75,,,percent of total billed charges,75% of total billed charges,3667.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5868,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4401,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7335,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1263.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3300.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5134.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4401,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2787.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5134.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3520.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7335,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7335,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1149.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1149.39,7335,
ROBOT IRRIGATION CLIP,3618523,CDM,272,RC,,,Outpatient,,,93.6,56.16,,16.85,18,,,percent of total billed charges,pays at 18% of total charges,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.8,50,,,percent of total billed charges,pays at 50% of total billed charges,65.52,70,,,percent of total billed charges,70% of total billed charges,70.2,75,,,percent of total billed charges,75% of total billed charges,46.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,65.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,84.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.67,93.6,
ROBOT FLUTED BALL BUR,3618524,CDM,272,RC,,,Outpatient,,,78.49,47.09,,14.13,18,,,percent of total billed charges,pays at 18% of total charges,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.25,50,,,percent of total billed charges,pays at 50% of total billed charges,54.94,70,,,percent of total billed charges,70% of total billed charges,58.87,75,,,percent of total billed charges,75% of total billed charges,39.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.49,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.3,78.49,
OMNIPORT 80 MM,3618533,CDM,272,RC,,,Outpatient,,,1013.5,608.1,,182.43,18,,,percent of total billed charges,pays at 18% of total charges,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,506.75,50,,,percent of total billed charges,pays at 50% of total billed charges,709.45,70,,,percent of total billed charges,70% of total billed charges,760.13,75,,,percent of total billed charges,75% of total billed charges,506.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,810.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,608.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,775.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,709.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,608.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,709.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1013.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,912.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.82,1013.5,
PLATE 4H,3618539,CDM,278,RC,C1713,HCPCS,Outpatient,,,346.5,207.9,,62.37,18,,,percent of total billed charges,pays at 18% of total charges,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.55,70,,,percent of total billed charges,70% of total billed charges,259.88,75,,,percent of total billed charges,75% of total billed charges,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,242.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,242.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,346.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,346.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.3,346.5,
SPRAY APPLICATOR,3618543,CDM,272,RC,,,Outpatient,,,156.5,93.9,,28.17,18,,,percent of total billed charges,pays at 18% of total charges,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.25,50,,,percent of total billed charges,pays at 50% of total billed charges,109.55,70,,,percent of total billed charges,70% of total billed charges,117.38,75,,,percent of total billed charges,75% of total billed charges,78.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,125.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,109.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,156.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,140.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.52,156.5,
BLADE REAMER,3618546,CDM,272,RC,,,Outpatient,,,418.5,251.1,,75.33,18,,,percent of total billed charges,pays at 18% of total charges,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.25,50,,,percent of total billed charges,pays at 50% of total billed charges,292.95,70,,,percent of total billed charges,70% of total billed charges,313.88,75,,,percent of total billed charges,75% of total billed charges,209.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,251.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,320.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,376.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.58,418.5,
KNOT CUTTER/PUSHER,3618552,CDM,272,RC,,,Outpatient,,,510,306,,91.8,18,,,percent of total billed charges,pays at 18% of total charges,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255,50,,,percent of total billed charges,pays at 50% of total billed charges,357,70,,,percent of total billed charges,70% of total billed charges,382.5,75,,,percent of total billed charges,75% of total billed charges,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,510,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,459,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.92,510,
IMPLANT PELVICOL 6X8,3618556,CDM,278,RC,C1762,HCPCS,Outpatient,,,1502.5,901.5,,270.45,18,,,percent of total billed charges,pays at 18% of total charges,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,270.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1051.75,70,,,percent of total billed charges,70% of total billed charges,1126.88,75,,,percent of total billed charges,75% of total billed charges,751.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1202,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1502.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,258.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1051.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,901.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,570.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1051.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1502.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1502.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.44,1502.5,
PLATE LCKG 4H,3618571,CDM,278,RC,C1713,HCPCS,Outpatient,,,1984,1190.4,,357.12,18,,,percent of total billed charges,pays at 18% of total charges,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,357.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1388.8,70,,,percent of total billed charges,70% of total billed charges,1488,75,,,percent of total billed charges,75% of total billed charges,992,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1190.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1984,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1388.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1190.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,753.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1388.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,952.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1984,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1984,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.89,1984,
LAP ENDOBABCOCK,3618702,CDM,272,RC,,,Outpatient,,,413.5,248.1,,74.43,18,,,percent of total billed charges,pays at 18% of total charges,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.75,50,,,percent of total billed charges,pays at 50% of total billed charges,289.45,70,,,percent of total billed charges,70% of total billed charges,310.13,75,,,percent of total billed charges,75% of total billed charges,206.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,248.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,289.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,289.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,413.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,372.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,413.5,
APPLIER LG,3618704,CDM,272,RC,,,Outpatient,,,635.5,381.3,,114.39,18,,,percent of total billed charges,pays at 18% of total charges,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.75,50,,,percent of total billed charges,pays at 50% of total billed charges,444.85,70,,,percent of total billed charges,70% of total billed charges,476.63,75,,,percent of total billed charges,75% of total billed charges,317.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,508.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,444.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,381.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,444.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,635.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,571.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.58,635.5,
LAP ENDOCLIP ML,3618706,CDM,272,RC,,,Outpatient,,,720.5,432.3,,129.69,18,,,percent of total billed charges,pays at 18% of total charges,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.25,50,,,percent of total billed charges,pays at 50% of total billed charges,504.35,70,,,percent of total billed charges,70% of total billed charges,540.38,75,,,percent of total billed charges,75% of total billed charges,360.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,576.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,504.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,432.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,273.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,504.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,720.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,648.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.9,720.5,
ENDO VESSEL HARVEST SYSTM DISP,3618709,CDM,272,RC,,,Outpatient,,,1397.5,838.5,,251.55,18,,,percent of total billed charges,pays at 18% of total charges,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.75,50,,,percent of total billed charges,pays at 50% of total billed charges,978.25,70,,,percent of total billed charges,70% of total billed charges,1048.13,75,,,percent of total billed charges,75% of total billed charges,698.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,838.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1069.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,978.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,838.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,531.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,978.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1397.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1257.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,1397.5,
LAP ENDO RETRACT,3618714,CDM,272,RC,,,Outpatient,,,392.5,235.5,,70.65,18,,,percent of total billed charges,pays at 18% of total charges,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,196.25,50,,,percent of total billed charges,pays at 50% of total billed charges,274.75,70,,,percent of total billed charges,70% of total billed charges,294.38,75,,,percent of total billed charges,75% of total billed charges,196.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,314,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,235.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,274.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,235.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,274.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,392.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,353.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.5,392.5,
LAP SURGIWAND II,3618726,CDM,272,RC,,,Outpatient,,,252,151.2,,45.36,18,,,percent of total billed charges,pays at 18% of total charges,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,50,,,percent of total billed charges,pays at 50% of total billed charges,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,252,
LAP TROCAR 10MM LNG USSC,3618729,CDM,272,RC,,,Outpatient,,,406.5,243.9,,73.17,18,,,percent of total billed charges,pays at 18% of total charges,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.25,50,,,percent of total billed charges,pays at 50% of total billed charges,284.55,70,,,percent of total billed charges,70% of total billed charges,304.88,75,,,percent of total billed charges,75% of total billed charges,203.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,325.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,284.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,284.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,406.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,365.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.7,406.5,
KIT WASHER DISP,3618732,CDM,272,RC,,,Outpatient,,,1036.1,621.66,,186.5,18,,,percent of total billed charges,pays at 18% of total charges,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,518.05,50,,,percent of total billed charges,pays at 50% of total billed charges,725.27,70,,,percent of total billed charges,70% of total billed charges,777.08,75,,,percent of total billed charges,75% of total billed charges,518.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,828.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,621.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,792.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,725.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,621.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,725.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1036.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,932.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.36,1036.1,
SCREW CORT,3618733,CDM,278,RC,C1713,HCPCS,Outpatient,,,52,31.2,,9.36,18,,,percent of total billed charges,pays at 18% of total charges,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.4,70,,,percent of total billed charges,70% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,52,
WASHER SPIKED,3618736,CDM,278,RC,C1713,HCPCS,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
TIBIAL INSERT,3618776,CDM,278,RC,C1776,HCPCS,Outpatient,,,2317.5,1390.5,,417.15,18,,,percent of total billed charges,pays at 18% of total charges,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1622.25,70,,,percent of total billed charges,70% of total billed charges,1738.13,75,,,percent of total billed charges,75% of total billed charges,1158.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1854,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1390.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2317.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,399.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1042.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1622.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1390.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,880.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1622.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1112.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2317.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2317.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.15,2317.5,
DBX MIX 15CC,3618777,CDM,278,RC,C9359,HCPCS,Outpatient,,,2900,1740,,522,18,,,percent of total billed charges,pays at 18% of total charges,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,522,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1450,50,,,percent of total billed charges,pays at 50% of total billed charges,2030,70,,,percent of total billed charges,70% of total billed charges,2175,75,,,percent of total billed charges,75% of total billed charges,1450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1740,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,499.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1305,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2030,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1740,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1102,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2030,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1392,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.43,2900,
DBX MIX,3618778,CDM,278,RC,C9359,HCPCS,Outpatient,,,1715.5,1029.3,,308.79,18,,,percent of total billed charges,pays at 18% of total charges,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,308.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,857.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1200.85,70,,,percent of total billed charges,70% of total billed charges,1286.63,75,,,percent of total billed charges,75% of total billed charges,857.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1372.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1029.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1715.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,295.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1200.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1029.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,651.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1200.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1715.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1715.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.82,1715.5,
SUTURE LASSO,3618779,CDM,272,RC,,,Outpatient,,,449.5,269.7,,80.91,18,,,percent of total billed charges,pays at 18% of total charges,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.75,50,,,percent of total billed charges,pays at 50% of total billed charges,314.65,70,,,percent of total billed charges,70% of total billed charges,337.13,75,,,percent of total billed charges,75% of total billed charges,224.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,359.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,314.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,314.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,449.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,404.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.44,449.5,
SCREW BIOTENDONESIS,3618786,CDM,278,RC,C1713,HCPCS,Outpatient,,,664.5,398.7,,119.61,18,,,percent of total billed charges,pays at 18% of total charges,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.15,70,,,percent of total billed charges,70% of total billed charges,498.38,75,,,percent of total billed charges,75% of total billed charges,332.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,531.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,398.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,465.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,465.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,664.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,664.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.13,664.5,
GRAFT PASSING WIRE,3618787,CDM,272,RC,,,Outpatient,,,253,151.8,,45.54,18,,,percent of total billed charges,pays at 18% of total charges,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.5,50,,,percent of total billed charges,pays at 50% of total billed charges,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,126.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,253,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.65,253,
GUIDEPIN 2.0,3618789,CDM,278,RC,,,Outpatient,,,60,36,,10.8,18,,,percent of total billed charges,pays at 18% of total charges,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30,50,,,percent of total billed charges,pays at 50% of total billed charges,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,60,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,60,
DRILL BIT,3618791,CDM,272,RC,,,Outpatient,,,462,277.2,,83.16,18,,,percent of total billed charges,pays at 18% of total charges,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231,50,,,percent of total billed charges,pays at 50% of total billed charges,323.4,70,,,percent of total billed charges,70% of total billed charges,346.5,75,,,percent of total billed charges,75% of total billed charges,231,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,369.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,462,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,415.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.4,462,
TIBIAL INSERT,3618801,CDM,278,RC,C1776,HCPCS,Outpatient,,,1335.5,801.3,,240.39,18,,,percent of total billed charges,pays at 18% of total charges,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,240.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,934.85,70,,,percent of total billed charges,70% of total billed charges,1001.63,75,,,percent of total billed charges,75% of total billed charges,667.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1068.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,801.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1335.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,230.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,934.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,801.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,934.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1335.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1335.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,209.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.27,1335.5,
HYDROSORB 10 X 22,3618813,CDM,278,RC,C1781,HCPCS,Outpatient,,,5981,3588.6,,1076.58,18,,,percent of total billed charges,pays at 18% of total charges,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1076.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4186.7,70,,,percent of total billed charges,70% of total billed charges,4485.75,75,,,percent of total billed charges,75% of total billed charges,2990.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3588.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5981,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1030.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2691.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4186.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3588.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2272.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4186.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2870.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5981,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5981,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.22,5981,
PLATE OLECRANON,3618821,CDM,278,RC,C1713,HCPCS,Outpatient,,,1575,945,,283.5,18,,,percent of total billed charges,pays at 18% of total charges,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,283.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.5,70,,,percent of total billed charges,70% of total billed charges,1181.25,75,,,percent of total billed charges,75% of total billed charges,787.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,945,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1575,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,271.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1102.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,945,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,598.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1102.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.8,1575,
PUMP PAIN CONTROL,3618833,CDM,272,RC,,,Outpatient,,,518.5,311.1,,93.33,18,,,percent of total billed charges,pays at 18% of total charges,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.25,50,,,percent of total billed charges,pays at 50% of total billed charges,362.95,70,,,percent of total billed charges,70% of total billed charges,388.88,75,,,percent of total billed charges,75% of total billed charges,259.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,414.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,518.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,466.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.25,518.5,
BLADE HELICAL SCREW,3618839,CDM,278,RC,C1713,HCPCS,Outpatient,,,861.5,516.9,,155.07,18,,,percent of total billed charges,pays at 18% of total charges,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.05,70,,,percent of total billed charges,70% of total billed charges,646.13,75,,,percent of total billed charges,75% of total billed charges,430.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,689.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,861.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,148.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,603.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,516.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,603.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,861.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,861.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,861.5,
CEMENT BONE,3618876,CDM,278,RC,C1713,HCPCS,Outpatient,,,138.5,83.1,,24.93,18,,,percent of total billed charges,pays at 18% of total charges,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.95,70,,,percent of total billed charges,70% of total billed charges,103.88,75,,,percent of total billed charges,75% of total billed charges,69.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,138.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,138.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,138.5,
PLATE 6H X 2.0,3618883,CDM,278,RC,C1713,HCPCS,Outpatient,,,409.5,245.7,,73.71,18,,,percent of total billed charges,pays at 18% of total charges,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,70,,,percent of total billed charges,70% of total billed charges,307.13,75,,,percent of total billed charges,75% of total billed charges,204.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,327.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,409.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.17,409.5,
PLATE 8H X 2.0,3618884,CDM,278,RC,C1713,HCPCS,Outpatient,,,408.5,245.1,,73.53,18,,,percent of total billed charges,pays at 18% of total charges,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.95,70,,,percent of total billed charges,70% of total billed charges,306.38,75,,,percent of total billed charges,75% of total billed charges,204.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,326.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,285.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,285.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,408.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,408.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.01,408.5,
SCREW 2.0,3618886,CDM,278,RC,C1713,HCPCS,Outpatient,,,98.5,59.1,,17.73,18,,,percent of total billed charges,pays at 18% of total charges,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.95,70,,,percent of total billed charges,70% of total billed charges,73.88,75,,,percent of total billed charges,75% of total billed charges,49.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,98.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.43,98.5,
PROBE ABLATION FLEX,3618892,CDM,272,RC,,,Outpatient,,,1450,870,,261,18,,,percent of total billed charges,pays at 18% of total charges,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,725,50,,,percent of total billed charges,pays at 50% of total billed charges,1015,70,,,percent of total billed charges,70% of total billed charges,1087.5,75,,,percent of total billed charges,75% of total billed charges,725,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,870,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1109.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1015,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,870,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1015,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1305,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.22,1450,
BLADE INCISOR,3618893,CDM,272,RC,,,Outpatient,,,260.5,156.3,,46.89,18,,,percent of total billed charges,pays at 18% of total charges,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.25,50,,,percent of total billed charges,pays at 50% of total billed charges,182.35,70,,,percent of total billed charges,70% of total billed charges,195.38,75,,,percent of total billed charges,75% of total billed charges,130.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,260.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,234.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.82,260.5,
SCREW CORT 3.5,3618922,CDM,278,RC,C1713,HCPCS,Outpatient,,,109,65.4,,19.62,18,,,percent of total billed charges,pays at 18% of total charges,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,54.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,109,
DRILL RECON STEP,3618930,CDM,272,RC,,,Outpatient,,,1720.6,1032.36,,309.71,18,,,percent of total billed charges,pays at 18% of total charges,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,860.3,50,,,percent of total billed charges,pays at 50% of total billed charges,1204.42,70,,,percent of total billed charges,70% of total billed charges,1290.45,75,,,percent of total billed charges,75% of total billed charges,860.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1376.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1316.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1204.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1032.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,653.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1204.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1720.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1548.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.62,1720.6,
DRILL QUICK RELEASE,3618931,CDM,272,RC,,,Outpatient,,,103.5,62.1,,18.63,18,,,percent of total billed charges,pays at 18% of total charges,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.75,50,,,percent of total billed charges,pays at 50% of total billed charges,72.45,70,,,percent of total billed charges,70% of total billed charges,77.63,75,,,percent of total billed charges,75% of total billed charges,51.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.22,103.5,
DRAIN HEMOVAC SM,3618939,CDM,272,RC,C1729,HCPCS,Outpatient,,,91.5,54.9,,16.47,18,,,percent of total billed charges,pays at 18% of total charges,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.05,70,,,percent of total billed charges,70% of total billed charges,68.63,75,,,percent of total billed charges,75% of total billed charges,45.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,73.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,91.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,82.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,91.5,
SUTURE FLEXON,3618958,CDM,272,RC,,,Outpatient,,,73.5,44.1,,13.23,18,,,percent of total billed charges,pays at 18% of total charges,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,50,,,percent of total billed charges,pays at 50% of total billed charges,51.45,70,,,percent of total billed charges,70% of total billed charges,55.13,75,,,percent of total billed charges,75% of total billed charges,36.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,66.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,73.5,
CONNECTOR Y,3618961,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
HEMOVAC MED,3618962,CDM,272,RC,C1729,HCPCS,Outpatient,,,89.5,53.7,,16.11,18,,,percent of total billed charges,pays at 18% of total charges,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,44.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
CONNECTOR CSF CATH,3618963,CDM,278,RC,,,Outpatient,,,290,174,,52.2,18,,,percent of total billed charges,pays at 18% of total charges,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145,50,,,percent of total billed charges,pays at 50% of total billed charges,203,70,,,percent of total billed charges,70% of total billed charges,217.5,75,,,percent of total billed charges,75% of total billed charges,145,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,203,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,290,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,290,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.44,290,
SURGIVAC HEMOVAC,3618964,CDM,272,RC,C1729,HCPCS,Outpatient,,,222.5,133.5,,40.05,18,,,percent of total billed charges,pays at 18% of total charges,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.75,70,,,percent of total billed charges,70% of total billed charges,166.88,75,,,percent of total billed charges,75% of total billed charges,111.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,222.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,200.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.87,222.5,
VALVE CSF PROG RT ANGLE W SIPHON,3618965,CDM,278,RC,,,Outpatient,,,6515,3909,,1172.7,18,,,percent of total billed charges,pays at 18% of total charges,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1172.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3257.5,50,,,percent of total billed charges,pays at 50% of total billed charges,4560.5,70,,,percent of total billed charges,70% of total billed charges,4886.25,75,,,percent of total billed charges,75% of total billed charges,3257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3909,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6515,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2931.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4560.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3909,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2475.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4560.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3127.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.9,6515,
KIT CSF BACTISEAL CATHETERS,3618967,CDM,278,RC,,,Outpatient,,,1045,627,,188.1,18,,,percent of total billed charges,pays at 18% of total charges,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,522.5,50,,,percent of total billed charges,pays at 50% of total billed charges,731.5,70,,,percent of total billed charges,70% of total billed charges,783.75,75,,,percent of total billed charges,75% of total billed charges,522.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1045,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,731.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,627,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,731.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1045,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1045,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.75,1045,
BLADES SAW RECIP,3618969,CDM,272,RC,,,Outpatient,,,101,60.6,,18.18,18,,,percent of total billed charges,pays at 18% of total charges,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.5,50,,,percent of total billed charges,pays at 50% of total billed charges,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,101,
DEVICE CSF CONTROL SIPHON,3618970,CDM,278,RC,,,Outpatient,,,988,592.8,,177.84,18,,,percent of total billed charges,pays at 18% of total charges,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,494,50,,,percent of total billed charges,pays at 50% of total billed charges,691.6,70,,,percent of total billed charges,70% of total billed charges,741,75,,,percent of total billed charges,75% of total billed charges,494,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,988,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,691.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,691.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,988,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,988,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.82,988,
BUR ROUND,3618971,CDM,272,RC,,,Outpatient,,,263.5,158.1,,47.43,18,,,percent of total billed charges,pays at 18% of total charges,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.75,50,,,percent of total billed charges,pays at 50% of total billed charges,184.45,70,,,percent of total billed charges,70% of total billed charges,197.63,75,,,percent of total billed charges,75% of total billed charges,131.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,210.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,184.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,263.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,237.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.29,263.5,
CATHETER VENTRICULAR BACTISEAL,3618972,CDM,278,RC,C1729,HCPCS,Outpatient,,,593,355.8,,106.74,18,,,percent of total billed charges,pays at 18% of total charges,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.1,70,,,percent of total billed charges,70% of total billed charges,444.75,75,,,percent of total billed charges,75% of total billed charges,296.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,593,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,415.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,415.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,593,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,593,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.92,593,
CATHETER PERITONEAL BACTISEAL,3618973,CDM,278,RC,C1750,HCPCS,Outpatient,,,593,355.8,,106.74,18,,,percent of total billed charges,pays at 18% of total charges,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.1,70,,,percent of total billed charges,70% of total billed charges,444.75,75,,,percent of total billed charges,75% of total billed charges,296.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,355.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,593,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,415.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,415.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,593,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,593,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.92,593,
SCREW SET,3618975,CDM,278,RC,C1713,HCPCS,Outpatient,,,240.5,144.3,,43.29,18,,,percent of total billed charges,pays at 18% of total charges,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.35,70,,,percent of total billed charges,70% of total billed charges,180.38,75,,,percent of total billed charges,75% of total billed charges,120.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,240.5,
TIBIAL XLINK INSERT,3618977,CDM,278,RC,C1776,HCPCS,Outpatient,,,2142,1285.2,,385.56,18,,,percent of total billed charges,pays at 18% of total charges,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1499.4,70,,,percent of total billed charges,70% of total billed charges,1606.5,75,,,percent of total billed charges,75% of total billed charges,1071,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1713.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1285.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2142,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,369.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,963.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1499.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1285.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,813.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1499.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1028.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2142,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2142,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.65,2142,
BUR ROUND,3618978,CDM,272,RC,,,Outpatient,,,381.62,228.97,,68.69,18,,,percent of total billed charges,pays at 18% of total charges,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.81,50,,,percent of total billed charges,pays at 50% of total billed charges,267.13,70,,,percent of total billed charges,70% of total billed charges,286.22,75,,,percent of total billed charges,75% of total billed charges,190.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,305.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,267.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,267.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,381.62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,343.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.8,381.62,
LIGHT SOURCE DISPOSABLE,3618981,CDM,272,RC,,,Outpatient,,,760,456,,136.8,18,,,percent of total billed charges,pays at 18% of total charges,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380,50,,,percent of total billed charges,pays at 50% of total billed charges,532,70,,,percent of total billed charges,70% of total billed charges,570,75,,,percent of total billed charges,75% of total billed charges,380,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,581.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,456,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,684,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.09,760,
KNIFE BAYONET,3618983,CDM,272,RC,,,Outpatient,,,604,362.4,,108.72,18,,,percent of total billed charges,pays at 18% of total charges,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302,50,,,percent of total billed charges,pays at 50% of total billed charges,422.8,70,,,percent of total billed charges,70% of total billed charges,453,75,,,percent of total billed charges,75% of total billed charges,302,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,422.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,422.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,604,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,543.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.65,604,
TIBIAL TRAY,3619009,CDM,278,RC,C1776,HCPCS,Outpatient,,,2106.5,1263.9,,379.17,18,,,percent of total billed charges,pays at 18% of total charges,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,379.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1474.55,70,,,percent of total billed charges,70% of total billed charges,1579.88,75,,,percent of total billed charges,75% of total billed charges,1053.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1685.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1263.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2106.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,362.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,947.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1474.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1263.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,800.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1474.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2106.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2106.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.09,2106.5,
FEMORAL HEAD,3619011,CDM,278,RC,C1776,HCPCS,Outpatient,,,1680,1008,,302.4,18,,,percent of total billed charges,pays at 18% of total charges,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,70,,,percent of total billed charges,70% of total billed charges,1260,75,,,percent of total billed charges,75% of total billed charges,840,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1008,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1680,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,289.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,638.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1680,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1680,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.26,1680,
KIT SHOULDER STABILIZER,3619014,CDM,272,RC,,,Outpatient,,,108,64.8,,19.44,18,,,percent of total billed charges,pays at 18% of total charges,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,50,,,percent of total billed charges,pays at 50% of total billed charges,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,108,
KIT WRIST STABILIZATION,3619015,CDM,272,RC,,,Outpatient,,,129.3,77.58,,23.27,18,,,percent of total billed charges,pays at 18% of total charges,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.65,50,,,percent of total billed charges,pays at 50% of total billed charges,90.51,70,,,percent of total billed charges,70% of total billed charges,96.98,75,,,percent of total billed charges,75% of total billed charges,64.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,90.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,129.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.26,129.3,
CATH VENTRICULAR PORTNOY,3619017,CDM,272,RC,,,Outpatient,,,498,298.8,,89.64,18,,,percent of total billed charges,pays at 18% of total charges,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249,50,,,percent of total billed charges,pays at 50% of total billed charges,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,249,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,498,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.04,498,
TIBIAL BEARING,3619022,CDM,278,RC,C1776,HCPCS,Outpatient,,,1973,1183.8,,355.14,18,,,percent of total billed charges,pays at 18% of total charges,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.1,70,,,percent of total billed charges,70% of total billed charges,1479.75,75,,,percent of total billed charges,75% of total billed charges,986.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1578.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1183.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1973,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,339.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1381.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1183.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,749.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1381.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,947.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1973,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1973,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.17,1973,
ROD KNODT THRD,3619029,CDM,278,RC,C1713,HCPCS,Outpatient,,,546,327.6,,98.28,18,,,percent of total billed charges,pays at 18% of total charges,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.2,70,,,percent of total billed charges,70% of total billed charges,409.5,75,,,percent of total billed charges,75% of total billed charges,273,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,436.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,382.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,327.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,382.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,546,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,546,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.56,546,
TUBE VENT PE,3619044,CDM,272,RC,,,Outpatient,,,56.5,33.9,,10.17,18,,,percent of total billed charges,pays at 18% of total charges,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.25,50,,,percent of total billed charges,pays at 50% of total billed charges,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,56.5,
RETRACTOR HERCULES DISP,3619055,CDM,272,RC,,,Outpatient,,,330,198,,59.4,18,,,percent of total billed charges,pays at 18% of total charges,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,50,,,percent of total billed charges,pays at 50% of total billed charges,231,70,,,percent of total billed charges,70% of total billed charges,247.5,75,,,percent of total billed charges,75% of total billed charges,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,297,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.71,330,
RETRACTOR V,3619056,CDM,272,RC,,,Outpatient,,,164,98.4,,29.52,18,,,percent of total billed charges,pays at 18% of total charges,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,164,
KIT DCI ACCESSORY,3619057,CDM,272,RC,,,Outpatient,,,303.5,182.1,,54.63,18,,,percent of total billed charges,pays at 18% of total charges,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.75,50,,,percent of total billed charges,pays at 50% of total billed charges,212.45,70,,,percent of total billed charges,70% of total billed charges,227.63,75,,,percent of total billed charges,75% of total billed charges,151.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,303.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,273.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.56,303.5,
KIT LEAD INTRODUCER,3619059,CDM,272,RC,C1894,HCPCS,Outpatient,,,411,246.6,,73.98,18,,,percent of total billed charges,pays at 18% of total charges,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.7,70,,,percent of total billed charges,70% of total billed charges,308.25,75,,,percent of total billed charges,75% of total billed charges,205.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,328.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,411,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,369.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.4,411,
CABLE TWIST LOCK,3619060,CDM,272,RC,,,Outpatient,,,118,70.8,,21.24,18,,,percent of total billed charges,pays at 18% of total charges,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59,50,,,percent of total billed charges,pays at 50% of total billed charges,82.6,70,,,percent of total billed charges,70% of total billed charges,88.5,75,,,percent of total billed charges,75% of total billed charges,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,118,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,118,
SCREW PEDICLE 5.5,3619062,CDM,278,RC,C1713,HCPCS,Outpatient,,,1844,1106.4,,331.92,18,,,percent of total billed charges,pays at 18% of total charges,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290.8,70,,,percent of total billed charges,70% of total billed charges,1383,75,,,percent of total billed charges,75% of total billed charges,922,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1106.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1844,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,317.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,829.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1290.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1106.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,700.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1290.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1844,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1844,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.95,1844,
KIT PEDICLE ACCESS,3619063,CDM,272,RC,,,Outpatient,,,1040,624,,187.2,18,,,percent of total billed charges,pays at 18% of total charges,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,1040,
SCREW PEDICLE,3619064,CDM,278,RC,C1713,HCPCS,Outpatient,,,7627.1,4576.26,,1372.88,18,,,percent of total billed charges,pays at 18% of total charges,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1372.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5338.97,70,,,percent of total billed charges,70% of total billed charges,5720.33,75,,,percent of total billed charges,75% of total billed charges,3813.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6101.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4576.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7627.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1314.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5338.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4576.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2898.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5338.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3661.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7627.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7627.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1195.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1195.17,7627.1,
STIMULATOR TEST INTERSTIM,3619065,CDM,272,RC,,,Outpatient,,,510,306,,91.8,18,,,percent of total billed charges,pays at 18% of total charges,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255,50,,,percent of total billed charges,pays at 50% of total billed charges,357,70,,,percent of total billed charges,70% of total billed charges,382.5,75,,,percent of total billed charges,75% of total billed charges,255,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,510,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,459,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.92,510,
CABLE MINI HOOK,3619069,CDM,272,RC,,,Outpatient,,,69,41.4,,12.42,18,,,percent of total billed charges,pays at 18% of total charges,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.5,50,,,percent of total billed charges,pays at 50% of total billed charges,48.3,70,,,percent of total billed charges,70% of total billed charges,51.75,75,,,percent of total billed charges,75% of total billed charges,34.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,48.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,69,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,62.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.81,69,
LEAD TINED INTERSTIM,3619070,CDM,278,RC,C1778,HCPCS,Outpatient,,,4529,2717.4,,815.22,18,,,percent of total billed charges,pays at 18% of total charges,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,815.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3170.3,70,,,percent of total billed charges,70% of total billed charges,3396.75,75,,,percent of total billed charges,75% of total billed charges,2264.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3623.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2717.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4529,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,780.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3170.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2717.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1721.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3170.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2173.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4529,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4529,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,709.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.69,4529,
BONE VOID FILLER,3619071,CDM,278,RC,C9359,HCPCS,Outpatient,,,1204.5,722.7,,216.81,18,,,percent of total billed charges,pays at 18% of total charges,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,602.25,50,,,percent of total billed charges,pays at 50% of total billed charges,843.15,70,,,percent of total billed charges,70% of total billed charges,903.38,75,,,percent of total billed charges,75% of total billed charges,602.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,963.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,722.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1204.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,843.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,722.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,843.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1204.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1204.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.75,1204.5,
GENERATOR INTERSTIM,3619072,CDM,278,RC,C1767,HCPCS,Outpatient,,,14880,8928,,2678.4,18,,,percent of total billed charges,pays at 18% of total charges,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2678.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10416,70,,,percent of total billed charges,70% of total billed charges,11160,75,,,percent of total billed charges,75% of total billed charges,7440,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8928,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14880,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2563.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6696,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8928,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5654.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10416,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7142.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14880,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14880,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2331.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2331.7,14880,
PROGRAMMER HANDSET KIT,3619075,CDM,272,RC,,,Outpatient,,,2484,1490.4,,447.12,18,,,percent of total billed charges,pays at 18% of total charges,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1242,50,,,percent of total billed charges,pays at 50% of total billed charges,1738.8,70,,,percent of total billed charges,70% of total billed charges,1863,75,,,percent of total billed charges,75% of total billed charges,1242,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1490.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1900.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1117.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1738.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1490.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,943.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1738.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2484,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2235.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.24,2484,
RETRACTOR DISP METRX,3619076,CDM,272,RC,,,Outpatient,,,657.5,394.5,,118.35,18,,,percent of total billed charges,pays at 18% of total charges,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.75,50,,,percent of total billed charges,pays at 50% of total billed charges,460.25,70,,,percent of total billed charges,70% of total billed charges,493.13,75,,,percent of total billed charges,75% of total billed charges,328.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,526,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,394.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,502.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,460.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,394.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,460.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,657.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,591.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.03,657.5,
SCREW SLF DRLG,3619087,CDM,278,RC,C1713,HCPCS,Outpatient,,,553.5,332.1,,99.63,18,,,percent of total billed charges,pays at 18% of total charges,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.45,70,,,percent of total billed charges,70% of total billed charges,415.13,75,,,percent of total billed charges,75% of total billed charges,276.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,387.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,387.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,553.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,553.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,553.5,
AMS BONE ANCHOR POLY SUTR,3619092,CDM,278,RC,,,Outpatient,,,464,278.4,,83.52,18,,,percent of total billed charges,pays at 18% of total charges,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232,50,,,percent of total billed charges,pays at 50% of total billed charges,324.8,70,,,percent of total billed charges,70% of total billed charges,348,75,,,percent of total billed charges,75% of total billed charges,232,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,464,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,464,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,464,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.71,464,
ACETABULAR LINER,3619106,CDM,278,RC,C1776,HCPCS,Outpatient,,,1771.5,1062.9,,318.87,18,,,percent of total billed charges,pays at 18% of total charges,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,318.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1240.05,70,,,percent of total billed charges,70% of total billed charges,1328.63,75,,,percent of total billed charges,75% of total billed charges,885.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1417.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1062.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1771.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,305.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1240.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1062.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,673.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1240.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,850.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1771.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1771.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.59,1771.5,
SCREW 1.5,3619111,CDM,278,RC,C1713,HCPCS,Outpatient,,,79,47.4,,14.22,18,,,percent of total billed charges,pays at 18% of total charges,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.3,70,,,percent of total billed charges,70% of total billed charges,59.25,75,,,percent of total billed charges,75% of total billed charges,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,79,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,79,
PLATE TI 1.5,3619112,CDM,278,RC,C1713,HCPCS,Outpatient,,,367.5,220.5,,66.15,18,,,percent of total billed charges,pays at 18% of total charges,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.25,70,,,percent of total billed charges,70% of total billed charges,275.63,75,,,percent of total billed charges,75% of total billed charges,183.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,294,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,257.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,257.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,367.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,367.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.59,367.5,
PLATE LCKG T,3619114,CDM,278,RC,C1713,HCPCS,Outpatient,,,489.5,293.7,,88.11,18,,,percent of total billed charges,pays at 18% of total charges,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.65,70,,,percent of total billed charges,70% of total billed charges,367.13,75,,,percent of total billed charges,75% of total billed charges,244.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,391.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,489.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,342.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,293.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,342.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,489.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.7,489.5,
NAIL FEMORAL DIST,3619116,CDM,278,RC,C1713,HCPCS,Outpatient,,,2242,1345.2,,403.56,18,,,percent of total billed charges,pays at 18% of total charges,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1569.4,70,,,percent of total billed charges,70% of total billed charges,1681.5,75,,,percent of total billed charges,75% of total billed charges,1121,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1793.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1345.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2242,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,386.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1569.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1345.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,851.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1569.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1076.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2242,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2242,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.32,2242,
DEVICE ABLATION,3619117,CDM,272,RC,,,Outpatient,,,1780,1068,,320.4,18,,,percent of total billed charges,pays at 18% of total charges,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,890,50,,,percent of total billed charges,pays at 50% of total billed charges,1246,70,,,percent of total billed charges,70% of total billed charges,1335,75,,,percent of total billed charges,75% of total billed charges,890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1068,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1361.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1246,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1068,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,676.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1246,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1602,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.93,1780,
SYS PELVIC SLING,3619122,CDM,278,RC,C1771,HCPCS,Outpatient,,,2595,1557,,467.1,18,,,percent of total billed charges,pays at 18% of total charges,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.5,70,,,percent of total billed charges,70% of total billed charges,1946.25,75,,,percent of total billed charges,75% of total billed charges,1297.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2076,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1557,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2595,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,447.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1816.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1557,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,986.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1816.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2595,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2595,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.64,2595,
SYS HIP ACCESS CVD BLADE,3619123,CDM,272,RC,,,Outpatient,,,550.55,330.33,,99.1,18,,,percent of total billed charges,pays at 18% of total charges,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.28,50,,,percent of total billed charges,pays at 50% of total billed charges,385.39,70,,,percent of total billed charges,70% of total billed charges,412.91,75,,,percent of total billed charges,75% of total billed charges,275.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,440.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,385.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,550.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,495.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.27,550.55,
HUMERAL HEAD,3619126,CDM,278,RC,C1776,HCPCS,Outpatient,,,3036.5,1821.9,,546.57,18,,,percent of total billed charges,pays at 18% of total charges,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2125.55,70,,,percent of total billed charges,70% of total billed charges,2277.38,75,,,percent of total billed charges,75% of total billed charges,1518.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2429.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1821.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3036.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,523.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1366.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2125.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1821.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1153.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2125.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1457.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3036.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3036.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,475.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.82,3036.5,
DEPUY PROXIMAL SLEEVE,3619129,CDM,278,RC,,,Outpatient,,,2770,1662,,498.6,18,,,percent of total billed charges,pays at 18% of total charges,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1385,50,,,percent of total billed charges,pays at 50% of total billed charges,1939,70,,,percent of total billed charges,70% of total billed charges,2077.5,75,,,percent of total billed charges,75% of total billed charges,1385,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1662,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2770,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1246.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1939,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1662,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1052.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1939,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1329.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2770,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2770,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.06,2770,
GLIDEWIRE .025,3619156,CDM,272,RC,C1769,HCPCS,Outpatient,,,188,112.8,,33.84,18,,,percent of total billed charges,pays at 18% of total charges,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141,75,,,percent of total billed charges,75% of total billed charges,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,188,
TOOL VALVE ASST DISP,3619157,CDM,272,RC,,,Outpatient,,,330,198,,59.4,18,,,percent of total billed charges,pays at 18% of total charges,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165,50,,,percent of total billed charges,pays at 50% of total billed charges,231,70,,,percent of total billed charges,70% of total billed charges,247.5,75,,,percent of total billed charges,75% of total billed charges,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,297,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.71,330,
DEPUY TIBIAL TRAY,3619234,CDM,278,RC,C1776,HCPCS,Outpatient,,,3987,2392.2,,717.66,18,,,percent of total billed charges,pays at 18% of total charges,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,717.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2790.9,70,,,percent of total billed charges,70% of total billed charges,2990.25,75,,,percent of total billed charges,75% of total billed charges,1993.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2392.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3987,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,686.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1794.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2790.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2392.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1515.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2790.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1913.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3987,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3987,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,624.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.76,3987,
PLATE TIBIAL ANT LAT,3619238,CDM,278,RC,C1713,HCPCS,Outpatient,,,2254.5,1352.7,,405.81,18,,,percent of total billed charges,pays at 18% of total charges,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1578.15,70,,,percent of total billed charges,70% of total billed charges,1690.88,75,,,percent of total billed charges,75% of total billed charges,1127.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1803.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1352.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2254.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,388.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1578.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,856.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1578.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2254.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2254.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.28,2254.5,
BLADE REAMER,3619258,CDM,272,RC,,,Outpatient,,,444,266.4,,79.92,18,,,percent of total billed charges,pays at 18% of total charges,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222,50,,,percent of total billed charges,pays at 50% of total billed charges,310.8,70,,,percent of total billed charges,70% of total billed charges,333,75,,,percent of total billed charges,75% of total billed charges,222,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,355.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,339.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,310.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,310.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,444,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,399.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.57,444,
DRILL BIT 5.0,3619261,CDM,272,RC,,,Outpatient,,,389.5,233.7,,70.11,18,,,percent of total billed charges,pays at 18% of total charges,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.75,50,,,percent of total billed charges,pays at 50% of total billed charges,272.65,70,,,percent of total billed charges,70% of total billed charges,292.13,75,,,percent of total billed charges,75% of total billed charges,194.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,272.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.03,389.5,
PATIENT PROGRAMMER DCI,3619263,CDM,274,RC,L8681,HCPCS,Outpatient,,,1812.5,1087.5,,4362.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1232.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1232.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1268.75,70,,,percent of total billed charges,70% of total billed charges,1359.38,75,,,percent of total billed charges,75% of total billed charges,2218.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1450,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4313.51,350,,,Fee Schedule,350% of CMS OPPS Rate,1257.08,102,,,Fee Schedule,102% of CMS OPPS Rate,1812.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,312.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,815.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1268.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1087.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1232.43,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,688.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1268.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1232.43,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1812.5,230,,,Fee Schedule,230% of CMS OPPS Rate,870,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1232.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1812.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,284.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1232.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,284.02,4362.8,
CAGE SPINAL,3619297,CDM,278,RC,C1713,HCPCS,Outpatient,,,5887.5,3532.5,,1059.75,18,,,percent of total billed charges,pays at 18% of total charges,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4121.25,70,,,percent of total billed charges,70% of total billed charges,4415.63,75,,,percent of total billed charges,75% of total billed charges,2943.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4710,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3532.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5887.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1014.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2649.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4121.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3532.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2237.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4121.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2826,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5887.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5887.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,922.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.57,5887.5,
ROD 45MM,3619301,CDM,278,RC,C1713,HCPCS,Outpatient,,,801,480.6,,144.18,18,,,percent of total billed charges,pays at 18% of total charges,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.7,70,,,percent of total billed charges,70% of total billed charges,600.75,75,,,percent of total billed charges,75% of total billed charges,400.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,640.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,801,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,560.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,801,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,801,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.52,801,
GUIDEWIRE,3619302,CDM,272,RC,C1769,HCPCS,Outpatient,,,133.5,80.1,,24.03,18,,,percent of total billed charges,pays at 18% of total charges,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,75,,,percent of total billed charges,75% of total billed charges,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,133.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,133.5,
SCREW SET,3619309,CDM,278,RC,C1713,HCPCS,Outpatient,,,465,279,,83.7,18,,,percent of total billed charges,pays at 18% of total charges,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.5,70,,,percent of total billed charges,70% of total billed charges,348.75,75,,,percent of total billed charges,75% of total billed charges,232.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,465,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,325.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,325.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,465,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,465,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.87,465,
SCREW,3619321,CDM,278,RC,C1713,HCPCS,Outpatient,,,2462.5,1477.5,,443.25,18,,,percent of total billed charges,pays at 18% of total charges,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1723.75,70,,,percent of total billed charges,70% of total billed charges,1846.88,75,,,percent of total billed charges,75% of total billed charges,1231.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1970,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1477.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2462.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,424.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1723.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1477.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,935.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1723.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1182,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2462.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2462.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.87,2462.5,
SCREW SET,3619326,CDM,278,RC,C1713,HCPCS,Outpatient,,,327.5,196.5,,58.95,18,,,percent of total billed charges,pays at 18% of total charges,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.25,70,,,percent of total billed charges,70% of total billed charges,245.63,75,,,percent of total billed charges,75% of total billed charges,163.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,229.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,229.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,327.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.32,327.5,
SCREW SET LATERL CONNECTOR,3619327,CDM,278,RC,C1713,HCPCS,Outpatient,,,108,64.8,,19.44,18,,,percent of total billed charges,pays at 18% of total charges,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,108,
KIT LEAD TRIAL,3619329,CDM,278,RC,C1897,HCPCS,Outpatient,,,975,585,,175.5,18,,,percent of total billed charges,pays at 18% of total charges,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,167.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
CONNECTOR LATERAL,3619330,CDM,278,RC,,,Outpatient,,,1325,795,,238.5,18,,,percent of total billed charges,pays at 18% of total charges,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.5,50,,,percent of total billed charges,pays at 50% of total billed charges,927.5,70,,,percent of total billed charges,70% of total billed charges,993.75,75,,,percent of total billed charges,75% of total billed charges,662.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1325,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,927.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,927.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.63,1325,
CONNECTOR LATERAL,3619332,CDM,278,RC,,,Outpatient,,,862,517.2,,155.16,18,,,percent of total billed charges,pays at 18% of total charges,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,431,50,,,percent of total billed charges,pays at 50% of total billed charges,603.4,70,,,percent of total billed charges,70% of total billed charges,646.5,75,,,percent of total billed charges,75% of total billed charges,431,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,862,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,603.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,517.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,603.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,862,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,862,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.08,862,
INFUSE BONE GRAFT MED,3619339,CDM,278,RC,C1762,HCPCS,Outpatient,,,9298,5578.8,,1673.64,18,,,percent of total billed charges,pays at 18% of total charges,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1673.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6508.6,70,,,percent of total billed charges,70% of total billed charges,6973.5,75,,,percent of total billed charges,75% of total billed charges,4649,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7438.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5578.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9298,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1602.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4184.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6508.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5578.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3533.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6508.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4463.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9298,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9298,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1457,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1457,9298,
INFUSE BONE GRAFT LG,3619341,CDM,278,RC,C1762,HCPCS,Outpatient,,,10260.5,6156.3,,1846.89,18,,,percent of total billed charges,pays at 18% of total charges,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1846.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7182.35,70,,,percent of total billed charges,70% of total billed charges,7695.38,75,,,percent of total billed charges,75% of total billed charges,5130.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8208.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10260.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1767.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4617.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3898.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4925.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10260.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10260.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1607.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1607.82,10260.5,
GRAFT VASCULAR CARBON,3619352,CDM,278,RC,C1768,HCPCS,Outpatient,,,980.5,588.3,,176.49,18,,,percent of total billed charges,pays at 18% of total charges,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.35,70,,,percent of total billed charges,70% of total billed charges,735.38,75,,,percent of total billed charges,75% of total billed charges,490.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,784.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,588.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,980.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,168.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,686.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,588.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,686.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,980.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,980.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.64,980.5,
TIBIAL INSERT,3619356,CDM,278,RC,C1776,HCPCS,Outpatient,,,3324.5,1994.7,,598.41,18,,,percent of total billed charges,pays at 18% of total charges,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2327.15,70,,,percent of total billed charges,70% of total billed charges,2493.38,75,,,percent of total billed charges,75% of total billed charges,1662.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2659.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1994.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3324.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,572.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1496.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2327.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1994.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1263.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2327.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3324.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3324.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.95,3324.5,
BONE VOID FILLER,3619357,CDM,278,RC,C9359,HCPCS,Outpatient,,,4940,2964,,889.2,18,,,percent of total billed charges,pays at 18% of total charges,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,889.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2470,50,,,percent of total billed charges,pays at 50% of total billed charges,3458,70,,,percent of total billed charges,70% of total billed charges,3705,75,,,percent of total billed charges,75% of total billed charges,2470,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3952,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2964,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4940,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,851.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2223,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3458,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2964,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1877.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3458,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2371.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4940,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4940,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,774.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.1,4940,
CAP LOCKING,3619358,CDM,278,RC,C1713,HCPCS,Outpatient,,,330,198,,59.4,18,,,percent of total billed charges,pays at 18% of total charges,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231,70,,,percent of total billed charges,70% of total billed charges,247.5,75,,,percent of total billed charges,75% of total billed charges,165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.71,330,
CAP LCKG,3619360,CDM,278,RC,C1713,HCPCS,Outpatient,,,656.76,394.06,,118.22,18,,,percent of total billed charges,pays at 18% of total charges,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.73,70,,,percent of total billed charges,70% of total billed charges,492.57,75,,,percent of total billed charges,75% of total billed charges,328.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,525.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,394.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,656.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,113.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,459.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,394.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,459.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,656.76,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,656.76,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.91,656.76,
SUTURE CAPIO DEVICE,3619364,CDM,278,RC,C2631,HCPCS,Outpatient,,,410.5,246.3,,73.89,18,,,percent of total billed charges,pays at 18% of total charges,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.35,70,,,percent of total billed charges,70% of total billed charges,307.88,75,,,percent of total billed charges,75% of total billed charges,205.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,328.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,410.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,410.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,410.5,
PLATE MESH TITANIUM,3619366,CDM,278,RC,C1713,HCPCS,Outpatient,,,845,507,,152.1,18,,,percent of total billed charges,pays at 18% of total charges,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.5,70,,,percent of total billed charges,70% of total billed charges,633.75,75,,,percent of total billed charges,75% of total billed charges,422.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,507,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,845,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,145.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,591.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,507,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,591.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,845,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,845,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.41,845,
SCREW CORT PELVIC LNG,3619367,CDM,278,RC,C1713,HCPCS,Outpatient,,,90.9,54.54,,16.36,18,,,percent of total billed charges,pays at 18% of total charges,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,45.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.24,90.9,
SCREW CORTICAL,3619388,CDM,278,RC,C1713,HCPCS,Outpatient,,,210.5,126.3,,37.89,18,,,percent of total billed charges,pays at 18% of total charges,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.35,70,,,percent of total billed charges,70% of total billed charges,157.88,75,,,percent of total billed charges,75% of total billed charges,105.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,210.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,210.5,
PLATE HUMERAL PROX,3619389,CDM,278,RC,C1713,HCPCS,Outpatient,,,2150.5,1290.3,,387.09,18,,,percent of total billed charges,pays at 18% of total charges,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505.35,70,,,percent of total billed charges,70% of total billed charges,1612.88,75,,,percent of total billed charges,75% of total billed charges,1075.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1720.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1290.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2150.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,370.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1505.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1290.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,817.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1505.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1032.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2150.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2150.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.98,2150.5,
DRILL MINI DISP,3619412,CDM,272,RC,,,Outpatient,,,290,174,,52.2,18,,,percent of total billed charges,pays at 18% of total charges,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145,50,,,percent of total billed charges,pays at 50% of total billed charges,203,70,,,percent of total billed charges,70% of total billed charges,217.5,75,,,percent of total billed charges,75% of total billed charges,145,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,203,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,290,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,261,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.44,290,
SCREW BONE ACCUTRAK 2,3619413,CDM,278,RC,C1713,HCPCS,Outpatient,,,700,420,,126,18,,,percent of total billed charges,pays at 18% of total charges,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490,70,,,percent of total billed charges,70% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,700,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.69,700,
PIN GUIDE MINI,3619414,CDM,272,RC,,,Outpatient,,,30,18,,5.4,18,,,percent of total billed charges,pays at 18% of total charges,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15,50,,,percent of total billed charges,pays at 50% of total billed charges,21,70,,,percent of total billed charges,70% of total billed charges,22.5,75,,,percent of total billed charges,75% of total billed charges,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,30,
DRIVER HEX DISP,3619416,CDM,272,RC,,,Outpatient,,,306,183.6,,55.08,18,,,percent of total billed charges,pays at 18% of total charges,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,50,,,percent of total billed charges,pays at 50% of total billed charges,214.2,70,,,percent of total billed charges,70% of total billed charges,229.5,75,,,percent of total billed charges,75% of total billed charges,153,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,306,
DEVICE TROCH REATTACH,3619445,CDM,278,RC,C1713,HCPCS,Outpatient,,,5123,3073.8,,922.14,18,,,percent of total billed charges,pays at 18% of total charges,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,922.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3586.1,70,,,percent of total billed charges,70% of total billed charges,3842.25,75,,,percent of total billed charges,75% of total billed charges,2561.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4098.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3073.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5123,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,882.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2305.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3586.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3073.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1946.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3586.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2459.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,802.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.77,5123,
GRAFT GORE,3619446,CDM,278,RC,C1768,HCPCS,Outpatient,,,1214,728.4,,218.52,18,,,percent of total billed charges,pays at 18% of total charges,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.8,70,,,percent of total billed charges,70% of total billed charges,910.5,75,,,percent of total billed charges,75% of total billed charges,607,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,971.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,728.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1214,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,209.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,849.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,728.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,461.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,849.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.23,1214,
SCREW LCKG TI 2.4,3619447,CDM,278,RC,C1713,HCPCS,Outpatient,,,164,98.4,,29.52,18,,,percent of total billed charges,pays at 18% of total charges,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,164,
SCREW 4.5,3619448,CDM,278,RC,C1713,HCPCS,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,780,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
PINS DRILL BITS,3619453,CDM,272,RC,,,Outpatient,,,423,253.8,,76.14,18,,,percent of total billed charges,pays at 18% of total charges,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.5,50,,,percent of total billed charges,pays at 50% of total billed charges,296.1,70,,,percent of total billed charges,70% of total billed charges,317.25,75,,,percent of total billed charges,75% of total billed charges,211.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,423,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.28,423,
SCREW INTRAFIX FEMORAL,3619462,CDM,278,RC,C1713,HCPCS,Outpatient,,,643.5,386.1,,115.83,18,,,percent of total billed charges,pays at 18% of total charges,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.45,70,,,percent of total billed charges,70% of total billed charges,482.63,75,,,percent of total billed charges,75% of total billed charges,321.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,643.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,643.5,
CANNULA ARTERIAL FEM,3619469,CDM,272,RC,,,Outpatient,,,452.5,271.5,,81.45,18,,,percent of total billed charges,pays at 18% of total charges,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.25,50,,,percent of total billed charges,pays at 50% of total billed charges,316.75,70,,,percent of total billed charges,70% of total billed charges,339.38,75,,,percent of total billed charges,75% of total billed charges,226.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,362,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,452.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,452.5,
TORQUE DRIVER DISP,3619471,CDM,272,RC,,,Outpatient,,,573.5,344.1,,103.23,18,,,percent of total billed charges,pays at 18% of total charges,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.75,50,,,percent of total billed charges,pays at 50% of total billed charges,401.45,70,,,percent of total billed charges,70% of total billed charges,430.13,75,,,percent of total billed charges,75% of total billed charges,286.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,458.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,344.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,438.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,401.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,344.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,401.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,573.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,516.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.87,573.5,
FEMORAL STEM,3619474,CDM,278,RC,C1776,HCPCS,Outpatient,,,901,540.6,,162.18,18,,,percent of total billed charges,pays at 18% of total charges,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.7,70,,,percent of total billed charges,70% of total billed charges,675.75,75,,,percent of total billed charges,75% of total billed charges,450.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,540.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,901,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,630.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,901,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,901,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.19,901,
VALVE HEART MITRAL TISSUE,3619477,CDM,278,RC,,,Outpatient,,,11472.5,6883.5,,2065.05,18,,,percent of total billed charges,pays at 18% of total charges,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2065.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5736.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8030.75,70,,,percent of total billed charges,70% of total billed charges,8604.38,75,,,percent of total billed charges,75% of total billed charges,5736.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6883.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11472.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5162.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8030.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6883.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4359.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8030.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5506.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11472.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11472.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.74,11472.5,
TISSUE BUTTON,3619478,CDM,278,RC,,,Outpatient,,,650,390,,117,18,,,percent of total billed charges,pays at 18% of total charges,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325,50,,,percent of total billed charges,pays at 50% of total billed charges,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,325,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,650,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
SYS TAVR VALVE,3619479,CDM,278,RC,,,Outpatient,,,41600,24960,,7488,18,,,percent of total billed charges,pays at 18% of total charges,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7488,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20800,50,,,percent of total billed charges,pays at 50% of total billed charges,29120,70,,,percent of total billed charges,70% of total billed charges,31200,75,,,percent of total billed charges,75% of total billed charges,20800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15808,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19968,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6518.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.72,41600,
MESH PROLENE HERNIA,3619481,CDM,278,RC,C1781,HCPCS,Outpatient,,,698.5,419.1,,125.73,18,,,percent of total billed charges,pays at 18% of total charges,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.95,70,,,percent of total billed charges,70% of total billed charges,523.88,75,,,percent of total billed charges,75% of total billed charges,349.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,558.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,419.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,488.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,419.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,488.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,698.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,698.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.45,698.5,
HYDROSORB SHIELD 50 X 70,3619486,CDM,278,RC,C1781,HCPCS,Outpatient,,,1001.5,600.9,,180.27,18,,,percent of total billed charges,pays at 18% of total charges,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.05,70,,,percent of total billed charges,70% of total billed charges,751.13,75,,,percent of total billed charges,75% of total billed charges,500.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,801.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1001.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,701.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,600.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,701.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1001.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1001.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.94,1001.5,
PLATE ATLANTIS,3619488,CDM,278,RC,,,Outpatient,,,3347.5,2008.5,,602.55,18,,,percent of total billed charges,pays at 18% of total charges,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,602.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1673.75,50,,,percent of total billed charges,pays at 50% of total billed charges,2343.25,70,,,percent of total billed charges,70% of total billed charges,2510.63,75,,,percent of total billed charges,75% of total billed charges,1673.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2678,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2008.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3347.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1506.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2343.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2008.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1272.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2343.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1606.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3347.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3347.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.55,3347.5,
SCREW CANC LCKG 6.5,3619489,CDM,278,RC,C1713,HCPCS,Outpatient,,,783,469.8,,140.94,18,,,percent of total billed charges,pays at 18% of total charges,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.1,70,,,percent of total billed charges,70% of total billed charges,587.25,75,,,percent of total billed charges,75% of total billed charges,391.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,626.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,469.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,783,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,548.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,469.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,548.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,783,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,783,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.7,783,
DEVICE OPH VISCOSURGICAL,3619490,CDM,272,RC,,,Outpatient,,,209.4,125.64,,37.69,18,,,percent of total billed charges,pays at 18% of total charges,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.7,50,,,percent of total billed charges,pays at 50% of total billed charges,146.58,70,,,percent of total billed charges,70% of total billed charges,157.05,75,,,percent of total billed charges,75% of total billed charges,104.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,167.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,146.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,146.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,209.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,188.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.81,209.4,
PUTTY OSTEOSTIM DBM 10CC,3619504,CDM,278,RC,C9359,HCPCS,Outpatient,,,1978,1186.8,,356.04,18,,,percent of total billed charges,pays at 18% of total charges,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,989,50,,,percent of total billed charges,pays at 50% of total billed charges,1384.6,70,,,percent of total billed charges,70% of total billed charges,1483.5,75,,,percent of total billed charges,75% of total billed charges,989,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1582.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1186.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1978,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,340.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1384.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1186.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,751.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1384.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1978,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1978,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.95,1978,
STAPLER HEMORRHOID DISP,3619507,CDM,272,RC,,,Outpatient,,,604,362.4,,108.72,18,,,percent of total billed charges,pays at 18% of total charges,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302,50,,,percent of total billed charges,pays at 50% of total billed charges,422.8,70,,,percent of total billed charges,70% of total billed charges,453,75,,,percent of total billed charges,75% of total billed charges,302,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,483.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,422.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,422.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,604,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,543.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.65,604,
NDL ASPIRATION BONE MARROW,3619518,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
NEEDLE DELIVERY,3619520,CDM,272,RC,,,Outpatient,,,328.5,197.1,,59.13,18,,,percent of total billed charges,pays at 18% of total charges,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.25,50,,,percent of total billed charges,pays at 50% of total billed charges,229.95,70,,,percent of total billed charges,70% of total billed charges,246.38,75,,,percent of total billed charges,75% of total billed charges,164.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,229.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,229.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,328.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,295.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.48,328.5,
BONE FIBULA SHAFT,3619542,CDM,278,RC,,,Outpatient,,,1020.5,612.3,,183.69,18,,,percent of total billed charges,pays at 18% of total charges,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.25,50,,,percent of total billed charges,pays at 50% of total billed charges,714.35,70,,,percent of total billed charges,70% of total billed charges,765.38,75,,,percent of total billed charges,75% of total billed charges,510.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,816.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,612.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1020.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,714.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,612.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,714.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1020.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1020.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.91,1020.5,
PYRAMESH,3619544,CDM,278,RC,C1781,HCPCS,Outpatient,,,9575,5745,,1723.5,18,,,percent of total billed charges,pays at 18% of total charges,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1723.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6702.5,70,,,percent of total billed charges,70% of total billed charges,7181.25,75,,,percent of total billed charges,75% of total billed charges,4787.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7660,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5745,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9575,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1649.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4308.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6702.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5745,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3638.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6702.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4596,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1500.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1500.4,9575,
PLATE MICRO,3619546,CDM,278,RC,C1713,HCPCS,Outpatient,,,369.5,221.7,,66.51,18,,,percent of total billed charges,pays at 18% of total charges,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.65,70,,,percent of total billed charges,70% of total billed charges,277.13,75,,,percent of total billed charges,75% of total billed charges,184.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,295.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,221.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,258.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,258.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,369.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,369.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.9,369.5,
NEEDLE INJECTION,3619547,CDM,272,RC,,,Outpatient,,,71.5,42.9,,12.87,18,,,percent of total billed charges,pays at 18% of total charges,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.75,50,,,percent of total billed charges,pays at 50% of total billed charges,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,71.5,
TENDON ACHILLES,3619548,CDM,278,RC,C1762,HCPCS,Outpatient,,,2400,1440,,432,18,,,percent of total billed charges,pays at 18% of total charges,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,70,,,percent of total billed charges,70% of total billed charges,1800,75,,,percent of total billed charges,75% of total billed charges,1200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1440,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2400,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,413.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1440,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,912,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1152,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.08,2400,
TENDON ACHILLES,3619549,CDM,278,RC,C1762,HCPCS,Outpatient,,,3194.1,1916.46,,574.94,18,,,percent of total billed charges,pays at 18% of total charges,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2235.87,70,,,percent of total billed charges,70% of total billed charges,2395.58,75,,,percent of total billed charges,75% of total billed charges,1597.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2555.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1916.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3194.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,550.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1437.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2235.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1916.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1213.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2235.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1533.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3194.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3194.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,500.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.52,3194.1,
FEMORAL STEM,3619554,CDM,278,RC,C1776,HCPCS,Outpatient,,,3401,2040.6,,612.18,18,,,percent of total billed charges,pays at 18% of total charges,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2380.7,70,,,percent of total billed charges,70% of total billed charges,2550.75,75,,,percent of total billed charges,75% of total billed charges,1700.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2720.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3401,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2380.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2040.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1292.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2380.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1632.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3401,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3401,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.94,3401,
TENDON MENISCUS,3619557,CDM,278,RC,C1762,HCPCS,Outpatient,,,7020,4212,,1263.6,18,,,percent of total billed charges,pays at 18% of total charges,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1263.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4914,70,,,percent of total billed charges,70% of total billed charges,5265,75,,,percent of total billed charges,75% of total billed charges,3510,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5616,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4212,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7020,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1209.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3159,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4914,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4212,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2667.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4914,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3369.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7020,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7020,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.03,7020,
ACETABULAR CUP/SHELL,3619558,CDM,278,RC,C1776,HCPCS,Outpatient,,,3664.5,2198.7,,659.61,18,,,percent of total billed charges,pays at 18% of total charges,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,659.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2565.15,70,,,percent of total billed charges,70% of total billed charges,2748.38,75,,,percent of total billed charges,75% of total billed charges,1832.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2931.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2198.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3664.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,631.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1649.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2565.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2198.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1392.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2565.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1758.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3664.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3664.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.23,3664.5,
BONE HUMERUS PROXIMAL,3619559,CDM,278,RC,,,Outpatient,,,7038,4222.8,,1266.84,18,,,percent of total billed charges,pays at 18% of total charges,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3519,50,,,percent of total billed charges,pays at 50% of total billed charges,4926.6,70,,,percent of total billed charges,70% of total billed charges,5278.5,75,,,percent of total billed charges,75% of total billed charges,3519,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5630.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4222.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7038,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3167.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4926.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4222.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2674.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4926.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3378.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7038,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7038,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.85,7038,
TENDON ACHILLES,3619560,CDM,278,RC,C1762,HCPCS,Outpatient,,,3524,2114.4,,634.32,18,,,percent of total billed charges,pays at 18% of total charges,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,634.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2466.8,70,,,percent of total billed charges,70% of total billed charges,2643,75,,,percent of total billed charges,75% of total billed charges,1762,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2114.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3524,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,607.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2466.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2114.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1339.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2466.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1691.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3524,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3524,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,552.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.21,3524,
EXTRACTOR STONE,3619565,CDM,272,RC,,,Outpatient,,,132.5,79.5,,23.85,18,,,percent of total billed charges,pays at 18% of total charges,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.25,50,,,percent of total billed charges,pays at 50% of total billed charges,92.75,70,,,percent of total billed charges,70% of total billed charges,99.38,75,,,percent of total billed charges,75% of total billed charges,66.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.76,132.5,
RETRACTOR DISP,3619566,CDM,272,RC,,,Outpatient,,,370.5,222.3,,66.69,18,,,percent of total billed charges,pays at 18% of total charges,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.25,50,,,percent of total billed charges,pays at 50% of total billed charges,259.35,70,,,percent of total billed charges,70% of total billed charges,277.88,75,,,percent of total billed charges,75% of total billed charges,185.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,296.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,259.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,370.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,333.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.06,370.5,
RETRIEVER STONE,3619567,CDM,272,RC,,,Outpatient,,,518.5,311.1,,93.33,18,,,percent of total billed charges,pays at 18% of total charges,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.25,50,,,percent of total billed charges,pays at 50% of total billed charges,362.95,70,,,percent of total billed charges,70% of total billed charges,388.88,75,,,percent of total billed charges,75% of total billed charges,259.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,414.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,518.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,466.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.25,518.5,
NAIL TFN,3619568,CDM,278,RC,C1713,HCPCS,Outpatient,,,2386,1431.6,,429.48,18,,,percent of total billed charges,pays at 18% of total charges,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,429.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1670.2,70,,,percent of total billed charges,70% of total billed charges,1789.5,75,,,percent of total billed charges,75% of total billed charges,1193,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1908.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1431.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2386,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,411.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1073.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1670.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1431.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,906.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1670.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2386,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2386,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.89,2386,
NAIL TFN,3619569,CDM,278,RC,C1713,HCPCS,Outpatient,,,4429,2657.4,,797.22,18,,,percent of total billed charges,pays at 18% of total charges,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,797.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3100.3,70,,,percent of total billed charges,70% of total billed charges,3321.75,75,,,percent of total billed charges,75% of total billed charges,2214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3543.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2657.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4429,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,763.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1993.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3100.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2657.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1683.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3100.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2125.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.02,4429,
GRANULES MASTER GRAFT 5CC,3619573,CDM,278,RC,,,Outpatient,,,759,455.4,,136.62,18,,,percent of total billed charges,pays at 18% of total charges,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,379.5,50,,,percent of total billed charges,pays at 50% of total billed charges,531.3,70,,,percent of total billed charges,70% of total billed charges,569.25,75,,,percent of total billed charges,75% of total billed charges,379.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,607.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,455.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,759,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,531.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,455.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,531.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,759,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,759,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.94,759,
SCREW SEXTANT SET PEEK,3619574,CDM,278,RC,C1713,HCPCS,Outpatient,,,418,250.8,,75.24,18,,,percent of total billed charges,pays at 18% of total charges,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,209,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,418,
KIT DRAINAGE PLEURX,3619575,CDM,272,RC,,,Outpatient,,,103.25,61.95,,18.59,18,,,percent of total billed charges,pays at 18% of total charges,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.63,50,,,percent of total billed charges,pays at 50% of total billed charges,72.28,70,,,percent of total billed charges,70% of total billed charges,77.44,75,,,percent of total billed charges,75% of total billed charges,51.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.18,103.25,
SCREW ACUTRAK,3619578,CDM,278,RC,C1713,HCPCS,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
TRAY INSERTION PLEURX,3619580,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
CHEST DRAIN SYS,3619582,CDM,272,RC,,,Outpatient,,,111.5,66.9,,20.07,18,,,percent of total billed charges,pays at 18% of total charges,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.75,50,,,percent of total billed charges,pays at 50% of total billed charges,78.05,70,,,percent of total billed charges,70% of total billed charges,83.63,75,,,percent of total billed charges,75% of total billed charges,55.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.47,111.5,
KIT STARTER PLEURX,3619584,CDM,272,RC,,,Outpatient,,,1102.4,661.44,,198.43,18,,,percent of total billed charges,pays at 18% of total charges,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.2,50,,,percent of total billed charges,pays at 50% of total billed charges,771.68,70,,,percent of total billed charges,70% of total billed charges,826.8,75,,,percent of total billed charges,75% of total billed charges,551.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,881.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1102.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,992.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.75,1102.4,
VALVE CAP REPLACEMENT PLEURX,3619585,CDM,272,RC,,,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
FEMORAL HEAD,3619586,CDM,278,RC,C1776,HCPCS,Outpatient,,,1393.5,836.1,,250.83,18,,,percent of total billed charges,pays at 18% of total charges,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,975.45,70,,,percent of total billed charges,70% of total billed charges,1045.13,75,,,percent of total billed charges,75% of total billed charges,696.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1114.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1393.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,240.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,975.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,836.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,529.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,975.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,668.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1393.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1393.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.36,1393.5,
SYS CHEST TUBE W SUCTION,3619590,CDM,272,RC,,,Outpatient,,,579.15,347.49,,104.25,18,,,percent of total billed charges,pays at 18% of total charges,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,289.58,50,,,percent of total billed charges,pays at 50% of total billed charges,405.41,70,,,percent of total billed charges,70% of total billed charges,434.36,75,,,percent of total billed charges,75% of total billed charges,289.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,463.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,405.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,347.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,405.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,579.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,521.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.75,579.15,
KYPHEX XPANDER SYRINGE,3619591,CDM,272,RC,,,Outpatient,,,215.5,129.3,,38.79,18,,,percent of total billed charges,pays at 18% of total charges,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.75,50,,,percent of total billed charges,pays at 50% of total billed charges,150.85,70,,,percent of total billed charges,70% of total billed charges,161.63,75,,,percent of total billed charges,75% of total billed charges,107.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,150.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,150.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,215.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,193.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.77,215.5,
KYPHEX INTRODUCER SYS,3619593,CDM,272,RC,,,Outpatient,,,1990,1194,,358.2,18,,,percent of total billed charges,pays at 18% of total charges,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,995,50,,,percent of total billed charges,pays at 50% of total billed charges,1393,70,,,percent of total billed charges,70% of total billed charges,1492.5,75,,,percent of total billed charges,75% of total billed charges,995,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1194,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1522.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,895.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1393,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1194,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,756.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1393,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1990,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1791,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.83,1990,
KYPHEX BONE FILLER DEVICE,3619594,CDM,272,RC,,,Outpatient,,,222.5,133.5,,40.05,18,,,percent of total billed charges,pays at 18% of total charges,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.25,50,,,percent of total billed charges,pays at 50% of total billed charges,155.75,70,,,percent of total billed charges,70% of total billed charges,166.88,75,,,percent of total billed charges,75% of total billed charges,111.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,222.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,200.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.87,222.5,
LIGAMENT CHISEL,3619601,CDM,272,RC,,,Outpatient,,,819,491.4,,147.42,18,,,percent of total billed charges,pays at 18% of total charges,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.5,50,,,percent of total billed charges,pays at 50% of total billed charges,573.3,70,,,percent of total billed charges,70% of total billed charges,614.25,75,,,percent of total billed charges,75% of total billed charges,409.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,655.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,626.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,819,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,737.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.34,819,
KIT FOOT & ANKLE SUBCHONDROPLASTY,3619603,CDM,278,RC,C1713,HCPCS,Outpatient,,,5675,3405,,1021.5,18,,,percent of total billed charges,pays at 18% of total charges,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3972.5,70,,,percent of total billed charges,70% of total billed charges,4256.25,75,,,percent of total billed charges,75% of total billed charges,2837.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5675,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,977.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2553.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3972.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2156.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3972.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2724,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5675,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5675,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,889.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.27,5675,
INFUSE BONE GRAFT SM,3619604,CDM,278,RC,C1762,HCPCS,Outpatient,,,7329,4397.4,,1319.22,18,,,percent of total billed charges,pays at 18% of total charges,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1319.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5130.3,70,,,percent of total billed charges,70% of total billed charges,5496.75,75,,,percent of total billed charges,75% of total billed charges,3664.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5863.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4397.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7329,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1262.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3298.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5130.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4397.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2785.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5130.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3517.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7329,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7329,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1148.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1148.45,7329,
KIT KNEE SUBCHONDROPLASTY,3619605,CDM,278,RC,C1713,HCPCS,Outpatient,,,4907.5,2944.5,,883.35,18,,,percent of total billed charges,pays at 18% of total charges,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,883.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3435.25,70,,,percent of total billed charges,70% of total billed charges,3680.63,75,,,percent of total billed charges,75% of total billed charges,2453.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3926,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2944.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4907.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,845.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2208.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3435.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2944.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1864.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3435.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2355.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4907.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4907.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.01,4907.5,
KIT OSTEOCHONDRAL REPAIR,3619606,CDM,278,RC,C1713,HCPCS,Outpatient,,,1342,805.2,,241.56,18,,,percent of total billed charges,pays at 18% of total charges,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.4,70,,,percent of total billed charges,70% of total billed charges,1006.5,75,,,percent of total billed charges,75% of total billed charges,671,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1073.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,805.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1342,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,231.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,939.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,805.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,509.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,939.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,644.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1342,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1342,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.29,1342,
CHONDRAL DART,3619607,CDM,278,RC,,,Outpatient,,,283.5,170.1,,51.03,18,,,percent of total billed charges,pays at 18% of total charges,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,50,,,percent of total billed charges,pays at 50% of total billed charges,198.45,70,,,percent of total billed charges,70% of total billed charges,212.63,75,,,percent of total billed charges,75% of total billed charges,141.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,283.5,
KIT DISP ALLOGRAFT DELIVERY INST,3619609,CDM,272,RC,,,Outpatient,,,1885,1131,,339.3,18,,,percent of total billed charges,pays at 18% of total charges,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,942.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1319.5,70,,,percent of total billed charges,70% of total billed charges,1413.75,75,,,percent of total billed charges,75% of total billed charges,942.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1131,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1442.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1319.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1131,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,716.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1319.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,904.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1885,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1696.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.38,1885,
HUMERAL STEM DISTAL,3619610,CDM,278,RC,C1776,HCPCS,Outpatient,,,6334,3800.4,,1140.12,18,,,percent of total billed charges,pays at 18% of total charges,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4433.8,70,,,percent of total billed charges,70% of total billed charges,4750.5,75,,,percent of total billed charges,75% of total billed charges,3167,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5067.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3800.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6334,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1091.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2850.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4433.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3800.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2406.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4433.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3040.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6334,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6334,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.54,6334,
HUMERAL BODY PROXIMAL,3619611,CDM,278,RC,C1776,HCPCS,Outpatient,,,7037,4222.2,,1266.66,18,,,percent of total billed charges,pays at 18% of total charges,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4925.9,70,,,percent of total billed charges,70% of total billed charges,5277.75,75,,,percent of total billed charges,75% of total billed charges,3518.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5629.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4222.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7037,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1212.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3166.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4925.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4222.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2674.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4925.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3377.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7037,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7037,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1102.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.7,7037,
SCREW HUMERAL ASSEMBLY,3619612,CDM,278,RC,C1713,HCPCS,Outpatient,,,1407,844.2,,253.26,18,,,percent of total billed charges,pays at 18% of total charges,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,984.9,70,,,percent of total billed charges,70% of total billed charges,1055.25,75,,,percent of total billed charges,75% of total billed charges,703.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,844.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1407,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,242.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,984.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,844.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,534.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,984.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.48,1407,
SCREW HUMERAL ASSEMBLY,3619614,CDM,278,RC,C1713,HCPCS,Outpatient,,,4632,2779.2,,833.76,18,,,percent of total billed charges,pays at 18% of total charges,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,833.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3242.4,70,,,percent of total billed charges,70% of total billed charges,3474,75,,,percent of total billed charges,75% of total billed charges,2316,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3705.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2779.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4632,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,798.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2084.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2779.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1760.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3242.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2223.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4632,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4632,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,725.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.83,4632,
HUMERAL INSERT REVERSED,3619615,CDM,278,RC,C1776,HCPCS,Outpatient,,,1895,1137,,341.1,18,,,percent of total billed charges,pays at 18% of total charges,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.5,70,,,percent of total billed charges,70% of total billed charges,1421.25,75,,,percent of total billed charges,75% of total billed charges,947.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1137,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1895,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,326.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,852.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1326.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1137,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,720.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1326.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,909.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.95,1895,
PLATE LCKG OPEN WEDGE,3619617,CDM,278,RC,C1713,HCPCS,Outpatient,,,1199.25,719.55,,215.87,18,,,percent of total billed charges,pays at 18% of total charges,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.48,70,,,percent of total billed charges,70% of total billed charges,899.44,75,,,percent of total billed charges,75% of total billed charges,599.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,959.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,719.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1199.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,206.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,839.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,719.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,839.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1199.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1199.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.92,1199.25,
PLATE 1/3 TUBULAR,3619618,CDM,278,RC,C1713,HCPCS,Outpatient,,,288,172.8,,51.84,18,,,percent of total billed charges,pays at 18% of total charges,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,70,,,percent of total billed charges,70% of total billed charges,216,75,,,percent of total billed charges,75% of total billed charges,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,288,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,288,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.13,288,
DRAIN FLAT,3619621,CDM,272,RC,C1729,HCPCS,Outpatient,,,58,34.8,,10.44,18,,,percent of total billed charges,pays at 18% of total charges,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,58,
BONE PLUG,3619624,CDM,278,RC,,,Outpatient,,,239.5,143.7,,43.11,18,,,percent of total billed charges,pays at 18% of total charges,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.75,50,,,percent of total billed charges,pays at 50% of total billed charges,167.65,70,,,percent of total billed charges,70% of total billed charges,179.63,75,,,percent of total billed charges,75% of total billed charges,119.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,191.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,167.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.53,239.5,
IMPLANT CONTINUOUS COMPRESSION,3619625,CDM,278,RC,C1713,HCPCS,Outpatient,,,2845,1707,,512.1,18,,,percent of total billed charges,pays at 18% of total charges,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,512.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1991.5,70,,,percent of total billed charges,70% of total billed charges,2133.75,75,,,percent of total billed charges,75% of total billed charges,1422.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1707,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2845,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,490.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1991.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1707,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1081.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1991.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2845,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2845,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.81,2845,
KIT ACL DISP,3619631,CDM,272,RC,,,Outpatient,,,623.5,374.1,,112.23,18,,,percent of total billed charges,pays at 18% of total charges,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.75,50,,,percent of total billed charges,pays at 50% of total billed charges,436.45,70,,,percent of total billed charges,70% of total billed charges,467.63,75,,,percent of total billed charges,75% of total billed charges,311.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,498.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,476.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,436.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,374.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,436.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,623.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,561.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.7,623.5,
KIT FLEXBAND SOLO,3619632,CDM,272,RC,,,Outpatient,,,4415,2649,,794.7,18,,,percent of total billed charges,pays at 18% of total charges,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,794.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2207.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3090.5,70,,,percent of total billed charges,70% of total billed charges,3311.25,75,,,percent of total billed charges,75% of total billed charges,2207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3532,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2649,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3377.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1986.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3090.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2649,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1677.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3090.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4415,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3973.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.83,4415,
SOLN WOUND IRRIGATE,3619633,CDM,272,RC,,,Outpatient,,,252,151.2,,45.36,18,,,percent of total billed charges,pays at 18% of total charges,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,50,,,percent of total billed charges,pays at 50% of total billed charges,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,252,
TRAY SPINAL,3619649,CDM,272,RC,,,Outpatient,,,188,112.8,,33.84,18,,,percent of total billed charges,pays at 18% of total charges,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94,50,,,percent of total billed charges,pays at 50% of total billed charges,131.6,70,,,percent of total billed charges,70% of total billed charges,141,75,,,percent of total billed charges,75% of total billed charges,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,188,
SUSPENSORY,3619656,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
SUTURE MAXON,3619661,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
SUTURE POLYDEK,3619664,CDM,272,RC,,,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
BONE 15CC,3619678,CDM,278,RC,,,Outpatient,,,1851,1110.6,,333.18,18,,,percent of total billed charges,pays at 18% of total charges,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,925.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1295.7,70,,,percent of total billed charges,70% of total billed charges,1388.25,75,,,percent of total billed charges,75% of total billed charges,925.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1480.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1110.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1851,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,832.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1295.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1110.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,703.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1295.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1851,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1851,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.05,1851,
BLADE CAUTERY TEFLON CTD,3619699,CDM,272,RC,,,Outpatient,,,27.5,16.5,,4.95,18,,,percent of total billed charges,pays at 18% of total charges,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.75,50,,,percent of total billed charges,pays at 50% of total billed charges,19.25,70,,,percent of total billed charges,70% of total billed charges,20.63,75,,,percent of total billed charges,75% of total billed charges,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,27.5,
DEVICE N TRAD STONE,3619706,CDM,272,RC,,,Outpatient,,,340,204,,61.2,18,,,percent of total billed charges,pays at 18% of total charges,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170,50,,,percent of total billed charges,pays at 50% of total billed charges,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
WEDGE STEP,3619707,CDM,278,RC,C1713,HCPCS,Outpatient,,,2375,1425,,427.5,18,,,percent of total billed charges,pays at 18% of total charges,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.5,70,,,percent of total billed charges,70% of total billed charges,1781.25,75,,,percent of total billed charges,75% of total billed charges,1187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1425,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2375,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,409.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1662.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1425,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,902.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1662.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1140,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.16,2375,
PORT POWER,3619708,CDM,278,RC,C1788,HCPCS,Outpatient,,,595,357,,107.1,18,,,percent of total billed charges,pays at 18% of total charges,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.5,70,,,percent of total billed charges,70% of total billed charges,446.25,75,,,percent of total billed charges,75% of total billed charges,297.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,595,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,416.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,416.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,595,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,595,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.24,595,
FRACTURE MGMT KIT,3619709,CDM,278,RC,C1776,HCPCS,Outpatient,,,5195,3117,,935.1,18,,,percent of total billed charges,pays at 18% of total charges,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,935.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3636.5,70,,,percent of total billed charges,70% of total billed charges,3896.25,75,,,percent of total billed charges,75% of total billed charges,2597.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3117,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5195,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,895.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2337.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3636.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3117,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1974.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3636.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2493.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5195,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5195,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.06,5195,
WEDGE STEP,3619710,CDM,278,RC,C1713,HCPCS,Outpatient,,,520,312,,93.6,18,,,percent of total billed charges,pays at 18% of total charges,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,70,,,percent of total billed charges,70% of total billed charges,390,75,,,percent of total billed charges,75% of total billed charges,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,520,
ENDOLOOP PDS,3619711,CDM,272,RC,,,Outpatient,,,33.5,20.1,,6.03,18,,,percent of total billed charges,pays at 18% of total charges,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.75,50,,,percent of total billed charges,pays at 50% of total billed charges,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,16.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,33.5,
RING CG ANNULOPLASTY,3619712,CDM,278,RC,,,Outpatient,,,3822,2293.2,,687.96,18,,,percent of total billed charges,pays at 18% of total charges,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,687.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1911,50,,,percent of total billed charges,pays at 50% of total billed charges,2675.4,70,,,percent of total billed charges,70% of total billed charges,2866.5,75,,,percent of total billed charges,75% of total billed charges,1911,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3057.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2293.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3822,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2675.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2293.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1452.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2675.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1834.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3822,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3822,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,598.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.91,3822,
LENS CORRECTIVE IOL,3619716,CDM,276,RC,V2787,HCPCS,Outpatient,,,643.5,386.1,,115.83,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,115.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.75,50,,,percent of total billed charges,pays at 50% of total billed charges,450.45,70,,,percent of total billed charges,70% of total billed charges,482.63,75,,,percent of total billed charges,75% of total billed charges,321.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,492.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,579.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.83,643.5,
COLLAGEN WOUND GEL,3619724,CDM,272,RC,,,Outpatient,,,172.5,103.5,,31.05,18,,,percent of total billed charges,pays at 18% of total charges,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.25,50,,,percent of total billed charges,pays at 50% of total billed charges,120.75,70,,,percent of total billed charges,70% of total billed charges,129.38,75,,,percent of total billed charges,75% of total billed charges,86.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,120.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,172.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.03,172.5,
SCREW BIOTENDONESIS,3619781,CDM,278,RC,C1713,HCPCS,Outpatient,,,417,250.2,,75.06,18,,,percent of total billed charges,pays at 18% of total charges,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.9,70,,,percent of total billed charges,70% of total billed charges,312.75,75,,,percent of total billed charges,75% of total billed charges,208.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,333.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,291.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,417,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,417,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.34,417,
CATH BRONCHO,3619783,CDM,272,RC,,,Outpatient,,,97.5,58.5,,17.55,18,,,percent of total billed charges,pays at 18% of total charges,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.75,50,,,percent of total billed charges,pays at 50% of total billed charges,68.25,70,,,percent of total billed charges,70% of total billed charges,73.13,75,,,percent of total billed charges,75% of total billed charges,48.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,97.5,
CATH AIRWAY EXCHANGE,3619784,CDM,272,RC,,,Outpatient,,,85.8,51.48,,15.44,18,,,percent of total billed charges,pays at 18% of total charges,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.9,50,,,percent of total billed charges,pays at 50% of total billed charges,60.06,70,,,percent of total billed charges,70% of total billed charges,64.35,75,,,percent of total billed charges,75% of total billed charges,42.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,85.8,
Quantitative measure of glucose build up in the blood over time,3619809,CDM,301,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
CALCIUM IONIZED ABGS,3619809,CDM,301,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
POTASSIUM BLOOD,3619809,CDM,301,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
Test to measure arterial blood gases,3619809,CDM,301,RC,82803,HCPCS,Outpatient,,,290.79,174.47,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges,218.09,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,222.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of UHC Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,139.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,261.71,
Blood test to measure levels of hemoglobin,3619809,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
HCT HEMATOCRIT BLD,3619809,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
Test to measure arterial blood gases,3619811,CDM,301,RC,82803,HCPCS,Outpatient,,,290.79,174.47,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges,218.09,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,222.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of UHC Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,139.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,261.71,
CALCIUM IONIZED ABGS,3619812,CDM,301,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
POTASSIUM BLOOD,3619814,CDM,301,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
MESH LAP SLF FIXATING,3619816,CDM,278,RC,C1781,HCPCS,Outpatient,,,459.37,275.62,,,,,,Other,Not Separately reimbursable,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.56,70,,,percent of total billed charges,70% of total billed charges,344.53,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,367.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,321.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,321.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,459.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.98,459.37,
MESH BARD COMPOSIX 4X6,3619817,CDM,278,RC,C1781,HCPCS,Outpatient,,,643.5,386.1,,,,,,Other,Not Separately reimbursable,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.45,70,,,percent of total billed charges,70% of total billed charges,482.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,643.5,
HCT HEMATOCRIT BLD,3619818,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
Blood test to measure levels of hemoglobin,3619819,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
SCREW RETRO,3619820,CDM,278,RC,C1713,HCPCS,Outpatient,,,462,277.2,,,,,,Other,Not Separately reimbursable,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,70,,,percent of total billed charges,70% of total billed charges,346.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,369.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,462,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.4,462,
Quantitative measure of glucose build up in the blood over time,3619823,CDM,301,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
SODIUM SERUM,3619824,CDM,301,RC,84295,HCPCS,Outpatient,,,73.8,44.28,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,350,,,Fee Schedule,350% of CMS OPPS Rate,4.9,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,66.42,
WIRE BORING,3619826,CDM,272,RC,C1769,HCPCS,Outpatient,,,95.5,57.3,,,,,,Other,Not Separately reimbursable,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,66.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.96,85.95,
GRAFT SKIN THERASKIN PER SQCM,3619827,CDM,636,RC,Q4121,HCPCS,Outpatient,,,682.5,409.5,,,,,,Other,Not Separately reimbursable,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.25,50,,,percent of total billed charges,pays at 50% of total billed charges,477.75,70,,,percent of total billed charges,70% of total billed charges,511.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,546,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,409.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,614.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.95,614.25,
GRAFT SKIN THERASKIN PER SQCM,3619828,CDM,636,RC,Q4121,HCPCS,Outpatient,,,1202.5,721.5,,,,,,Other,Not Separately reimbursable,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.25,50,,,percent of total billed charges,pays at 50% of total billed charges,841.75,70,,,percent of total billed charges,70% of total billed charges,901.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,962,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,456.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1082.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.43,1082.25,
PACKING NASAL BIORESORBABLE,3619829,CDM,272,RC,,,Outpatient,,,210,126,,,,,,Other,Not Separately reimbursable,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,50,,,percent of total billed charges,pays at 50% of total billed charges,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,189,
STENT SINUS,3619830,CDM,278,RC,,,Outpatient,,,1235,741,,,,,,Other,Not Separately reimbursable,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.5,50,,,percent of total billed charges,pays at 50% of total billed charges,864.5,70,,,percent of total billed charges,70% of total billed charges,926.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,988,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.52,1235,
NASAL PCKG SINUS STENT,3619831,CDM,278,RC,,,Outpatient,,,135.5,81.3,,,,,,Other,Not Separately reimbursable,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.75,50,,,percent of total billed charges,pays at 50% of total billed charges,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,135.5,
SUCTION COAG W/HANDSWITCH,3619832,CDM,272,RC,,,Outpatient,,,29.5,17.7,,,,,,Other,Not Separately reimbursable,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,26.55,
GRAFT SKIN THERASKIN PER SQCM,3619833,CDM,636,RC,Q4121,HCPCS,Outpatient,,,323.74,194.24,,,,,,Other,Not Separately reimbursable,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.87,50,,,percent of total billed charges,pays at 50% of total billed charges,226.62,70,,,percent of total billed charges,70% of total billed charges,242.81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,258.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,226.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.73,291.37,
GRAFT SKIN THERASKIN WASTE PER SQ CM,3619838,CDM,636,RC,Q4121,HCPCS,Outpatient,,,682.5,409.5,,,,,,Other,Not Separately reimbursable,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.25,50,,,percent of total billed charges,pays at 50% of total billed charges,477.75,70,,,percent of total billed charges,70% of total billed charges,511.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,546,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,409.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,614.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.95,614.25,
GRAFT SKIN THERASKIN WASTE PER SQ CM,3619839,CDM,636,RC,Q4121,HCPCS,Outpatient,,,1202.5,721.5,,,,,,Other,Not Separately reimbursable,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.25,50,,,percent of total billed charges,pays at 50% of total billed charges,841.75,70,,,percent of total billed charges,70% of total billed charges,901.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,962,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,456.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1082.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.43,1082.25,
GRAFT SKIN THERASKIN WASTE PER SQ CM,3619842,CDM,636,RC,Q4121,HCPCS,Outpatient,,,323.74,194.24,,,,,,Other,Not Separately reimbursable,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.87,50,,,percent of total billed charges,pays at 50% of total billed charges,226.62,70,,,percent of total billed charges,70% of total billed charges,242.81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,258.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,226.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.73,291.37,
SCREW SET LEGACY,3619846,CDM,278,RC,C1713,HCPCS,Outpatient,,,299,179.4,,,,,,Other,Not Separately reimbursable,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.3,70,,,percent of total billed charges,70% of total billed charges,224.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,239.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,209.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,209.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.85,299,
HARMONIC ACE 36CM,3619847,CDM,272,RC,,,Outpatient,,,569,341.4,,,,,,Other,Not Separately reimbursable,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.5,50,,,percent of total billed charges,pays at 50% of total billed charges,398.3,70,,,percent of total billed charges,70% of total billed charges,426.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,455.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,398.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,341.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,398.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,512.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,512.1,
HARMONIC ACE 23 CM,3619848,CDM,272,RC,,,Outpatient,,,529,317.4,,,,,,Other,Not Separately reimbursable,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.5,50,,,percent of total billed charges,pays at 50% of total billed charges,370.3,70,,,percent of total billed charges,70% of total billed charges,396.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,423.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,370.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,317.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,370.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,476.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.89,476.1,
TISSUE REGENERATIVE,3619849,CDM,278,RC,,,Outpatient,,,5530.5,3318.3,,,,,,Other,Not Separately reimbursable,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2765.25,50,,,percent of total billed charges,pays at 50% of total billed charges,3871.35,70,,,percent of total billed charges,70% of total billed charges,4147.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5530.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2488.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3871.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2101.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3871.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2654.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5530.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,866.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,866.63,5530.5,
IMPLANT SALUTE 60G,3619851,CDM,278,RC,,,Outpatient,,,1038.5,623.1,,,,,,Other,Not Separately reimbursable,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.25,50,,,percent of total billed charges,pays at 50% of total billed charges,726.95,70,,,percent of total billed charges,70% of total billed charges,778.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,830.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,726.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,623.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,726.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1038.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.73,1038.5,
DEVICE TROCH REATTACH DEV,3619852,CDM,278,RC,C1713,HCPCS,Outpatient,,,2546,1527.6,,,,,,Other,Not Separately reimbursable,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1782.2,70,,,percent of total billed charges,70% of total billed charges,1909.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2036.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2546,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,438.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1782.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1527.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,967.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1782.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2546,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,398.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.96,2546,
CABLE W CRIMP,3619853,CDM,278,RC,C1713,HCPCS,Outpatient,,,642.5,385.5,,,,,,Other,Not Separately reimbursable,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.75,70,,,percent of total billed charges,70% of total billed charges,481.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,514,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,449.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,385.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,449.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,642.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.68,642.5,
FEMORAL STEM,3619854,CDM,278,RC,C1776,HCPCS,Outpatient,,,2788,1672.8,,,,,,Other,Not Separately reimbursable,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1951.6,70,,,percent of total billed charges,70% of total billed charges,2091,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2788,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,480.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1951.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1672.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1059.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1951.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1338.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2788,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,436.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.88,2788,
CABLE TROCHANTERIC GRIP,3619855,CDM,278,RC,C1713,HCPCS,Outpatient,,,2344,1406.4,,,,,,Other,Not Separately reimbursable,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1640.8,70,,,percent of total billed charges,70% of total billed charges,1758,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1875.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2344,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,403.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1054.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1640.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1406.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,890.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1640.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2344,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.3,2344,
PROBE PEDICLE,3619856,CDM,272,RC,,,Outpatient,,,975.5,585.3,,,,,,Other,Not Separately reimbursable,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.75,50,,,percent of total billed charges,pays at 50% of total billed charges,682.85,70,,,percent of total billed charges,70% of total billed charges,731.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,780.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,877.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.86,877.95,
TRAY BALLOON KYPHOPLASTY,3619858,CDM,272,RC,,,Outpatient,,,5021,3012.6,,,,,,Other,Not Separately reimbursable,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2510.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3514.7,70,,,percent of total billed charges,70% of total billed charges,3765.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4016.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3841.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2259.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1907.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2410.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4518.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.79,4518.9,
TRAY BALLOON KYPHOPLASTY,3619859,CDM,272,RC,,,Outpatient,,,5197.5,3118.5,,,,,,Other,Not Separately reimbursable,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2598.75,50,,,percent of total billed charges,pays at 50% of total billed charges,3638.25,70,,,percent of total billed charges,70% of total billed charges,3898.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3976.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2338.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3638.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1975.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3638.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2494.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4677.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.45,4677.75,
CARTRIDGE VACUUM CEMENT,3619860,CDM,272,RC,,,Outpatient,,,425,255,,,,,,Other,Not Separately reimbursable,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.5,50,,,percent of total billed charges,pays at 50% of total billed charges,297.5,70,,,percent of total billed charges,70% of total billed charges,318.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,340,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.6,382.5,
BLADE RADENOID,3619861,CDM,272,RC,,,Outpatient,,,197.5,118.5,,,,,,Other,Not Separately reimbursable,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,177.75,
TRAY KYPHOPAK EXPRESS,3619862,CDM,272,RC,,,Outpatient,,,3432.5,2059.5,,,,,,Other,Not Separately reimbursable,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1716.25,50,,,percent of total billed charges,pays at 50% of total billed charges,2402.75,70,,,percent of total billed charges,70% of total billed charges,2574.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2746,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1544.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2402.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2059.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1304.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2402.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1647.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3089.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.87,3089.25,
CABLE TROCHANTERIC GRIP,3619863,CDM,278,RC,C1713,HCPCS,Outpatient,,,3412.5,2047.5,,,,,,Other,Not Separately reimbursable,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2388.75,70,,,percent of total billed charges,70% of total billed charges,2559.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2730,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3412.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,587.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1535.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2388.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2047.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1296.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2388.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3412.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.74,3412.5,
TRAY DENTAL DISPOSABLE,3619866,CDM,272,RC,,,Outpatient,,,22,13.2,,,,,,Other,Not Separately reimbursable,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11,50,,,percent of total billed charges,pays at 50% of total billed charges,15.4,70,,,percent of total billed charges,70% of total billed charges,16.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.45,19.8,
K WIRE TI,3619869,CDM,272,RC,,,Outpatient,,,44,26.4,,,,,,Other,Not Separately reimbursable,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,50,,,percent of total billed charges,pays at 50% of total billed charges,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,39.6,
ANCHOR SUTURE BIOPUSHLOCK,3619872,CDM,278,RC,C1713,HCPCS,Outpatient,,,706,423.6,,,,,,Other,Not Separately reimbursable,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.2,70,,,percent of total billed charges,70% of total billed charges,529.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,564.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,494.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,423.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,494.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,706,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.63,706,
SCREW EXP,3619873,CDM,278,RC,C1713,HCPCS,Outpatient,,,1913,1147.8,,,,,,Other,Not Separately reimbursable,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1339.1,70,,,percent of total billed charges,70% of total billed charges,1434.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1530.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1913,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,329.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,860.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1339.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1147.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,726.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1339.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,918.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1913,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.77,1913,
SEALER BIPOLAR TISSUE LIN,3619877,CDM,272,RC,,,Outpatient,,,825.5,495.3,,,,,,Other,Not Separately reimbursable,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.75,50,,,percent of total billed charges,pays at 50% of total billed charges,577.85,70,,,percent of total billed charges,70% of total billed charges,619.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,660.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,495.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,577.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,742.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.36,742.95,
DRILL CANN  W/STOP,3619880,CDM,272,RC,,,Outpatient,,,532,319.2,,,,,,Other,Not Separately reimbursable,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266,50,,,percent of total billed charges,pays at 50% of total billed charges,372.4,70,,,percent of total billed charges,70% of total billed charges,399,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,425.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,372.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,319.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,372.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,478.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.36,478.8,
PATCH HERNIA PARASTOMAL,3619882,CDM,278,RC,C1781,HCPCS,Outpatient,,,1839.5,1103.7,,,,,,Other,Not Separately reimbursable,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287.65,70,,,percent of total billed charges,70% of total billed charges,1379.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1471.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1839.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,316.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1287.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1103.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,699.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1287.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.25,1839.5,
CARTRIDGE IMPLANT LAP,3619883,CDM,278,RC,,,Outpatient,,,549,329.4,,,,,,Other,Not Separately reimbursable,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.5,50,,,percent of total billed charges,pays at 50% of total billed charges,384.3,70,,,percent of total billed charges,70% of total billed charges,411.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,439.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,384.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,329.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,384.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.03,549,
HARMONIC ACE 14CM,3619884,CDM,272,RC,,,Outpatient,,,530.5,318.3,,,,,,Other,Not Separately reimbursable,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.25,50,,,percent of total billed charges,pays at 50% of total billed charges,371.35,70,,,percent of total billed charges,70% of total billed charges,397.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,477.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.13,477.45,
SYSTEM PERIGEE W INTEPRO,3619885,CDM,278,RC,C1771,HCPCS,Outpatient,,,2286,1371.6,,,,,,Other,Not Separately reimbursable,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600.2,70,,,percent of total billed charges,70% of total billed charges,1714.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1828.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2286,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,393.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1028.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1600.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1371.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,868.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1600.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1097.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2286,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.22,2286,
SYS ELEVATE PELVIC,3619886,CDM,278,RC,C1771,HCPCS,Outpatient,,,2860,1716,,,,,,Other,Not Separately reimbursable,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002,70,,,percent of total billed charges,70% of total billed charges,2145,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2860,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,492.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1086.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1372.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.16,2860,
SUTURE NYLON MONOFILAMENT,3619887,CDM,272,RC,,,Outpatient,,,53.5,32.1,,,,,,Other,Not Separately reimbursable,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,48.15,
SCREW CERV SLF RTNG,3619890,CDM,278,RC,C1713,HCPCS,Outpatient,,,453,271.8,,,,,,Other,Not Separately reimbursable,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.1,70,,,percent of total billed charges,70% of total billed charges,339.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,362.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,317.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,317.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.99,453,
FEMORAL COMPONENT,3619896,CDM,278,RC,C1776,HCPCS,Outpatient,,,6138.5,3683.1,,,,,,Other,Not Separately reimbursable,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4296.95,70,,,percent of total billed charges,70% of total billed charges,4603.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4910.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6138.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1057.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2762.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4296.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3683.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2332.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4296.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2946.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6138.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,961.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.9,6138.5,
PROBE PEDICLE SCREW DISP,3619898,CDM,272,RC,,,Outpatient,,,465.4,279.24,,,,,,Other,Not Separately reimbursable,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.7,50,,,percent of total billed charges,pays at 50% of total billed charges,325.78,70,,,percent of total billed charges,70% of total billed charges,349.05,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,372.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,325.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,325.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.93,418.86,
INFUSE BONE GRAFT XXSM,3619900,CDM,278,RC,C1762,HCPCS,Outpatient,,,1275,765,,,,,,Other,Not Separately reimbursable,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.5,70,,,percent of total billed charges,70% of total billed charges,956.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1275,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,219.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,892.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,765,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,484.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,892.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.79,1275,
PLATE THORACOLUMBER,3619901,CDM,278,RC,C1713,HCPCS,Outpatient,,,5765,3459,,,,,,Other,Not Separately reimbursable,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4035.5,70,,,percent of total billed charges,70% of total billed charges,4323.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5765,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,993.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2594.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4035.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3459,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2190.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4035.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2767.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5765,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,903.38,5765,
IMPLANT BIOWICK SURELOAD,3619902,CDM,278,RC,C1713,HCPCS,Outpatient,,,1831,1098.6,,,,,,Other,Not Separately reimbursable,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1281.7,70,,,percent of total billed charges,70% of total billed charges,1373.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1464.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1831,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,315.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1281.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1098.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,695.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1281.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1831,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.92,1831,
PATELLA BONE W/QUADRICEP TENDON,3619905,CDM,278,RC,C1762,HCPCS,Outpatient,,,7718,4630.8,,,,,,Other,Not Separately reimbursable,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5402.6,70,,,percent of total billed charges,70% of total billed charges,5788.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6174.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7718,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1329.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3473.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5402.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4630.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2932.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5402.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3704.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7718,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1209.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1209.41,7718,
CARTRIDGE IMPLANT,3619906,CDM,278,RC,,,Outpatient,,,1268,760.8,,,,,,Other,Not Separately reimbursable,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634,50,,,percent of total billed charges,pays at 50% of total billed charges,887.6,70,,,percent of total billed charges,70% of total billed charges,951,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,887.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,760.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,481.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,887.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1268,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.7,1268,
KIT CARTRIDGE HANDLE,3619907,CDM,272,RC,,,Outpatient,,,1268,760.8,,,,,,Other,Not Separately reimbursable,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634,50,,,percent of total billed charges,pays at 50% of total billed charges,887.6,70,,,percent of total billed charges,70% of total billed charges,951,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1014.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,887.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,760.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,481.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,887.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1141.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.7,1141.2,
BLADE SAW MICRO,3620002,CDM,272,RC,,,Outpatient,,,62,37.2,,,,,,Other,Not Separately reimbursable,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,55.8,
BLADE SAW MICRO,3620003,CDM,272,RC,,,Outpatient,,,80,48,,,,,,Other,Not Separately reimbursable,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,72,
GRAFT REVITA PER SQCM,3620005,CDM,278,RC,Q4180,HCPCS,Outpatient,,,173.34,104,,,,,,Other,Not Separately reimbursable,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.67,50,,,percent of total billed charges,pays at 50% of total billed charges,121.34,70,,,percent of total billed charges,70% of total billed charges,130.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,121.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,173.34,
KNIFE 15,3620010,CDM,272,RC,,,Outpatient,,,38,22.8,,,,,,Other,Not Separately reimbursable,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,34.2,
KNIFE SLIT,3620022,CDM,272,RC,,,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,74.7,
FEMORAL HEAD,3620027,CDM,278,RC,C1776,HCPCS,Outpatient,,,1212.5,727.5,,,,,,Other,Not Separately reimbursable,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.75,70,,,percent of total billed charges,70% of total billed charges,909.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,970,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,208.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,848.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,727.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,460.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,848.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1212.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190,1212.5,
RETRACTOR SUCTION TIP,3620033,CDM,272,RC,,,Outpatient,,,550,330,,,,,,Other,Not Separately reimbursable,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275,50,,,percent of total billed charges,pays at 50% of total billed charges,385,70,,,percent of total billed charges,70% of total billed charges,412.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,495,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.19,495,
DRILL BIT ADJ TRI FLAT,3620038,CDM,272,RC,,,Outpatient,,,440,264,,,,,,Other,Not Separately reimbursable,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220,50,,,percent of total billed charges,pays at 50% of total billed charges,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.95,396,
GLASSCOCK EAR DRSG,3620059,CDM,272,RC,,,Outpatient,,,56.5,33.9,,,,,,Other,Not Separately reimbursable,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,50,,,percent of total billed charges,pays at 50% of total billed charges,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,50.85,
VERTESTACK ADD ON,3620077,CDM,278,RC,C1821,HCPCS,Outpatient,,,6518.5,3911.1,,,,,,Other,Not Separately reimbursable,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4562.95,70,,,percent of total billed charges,70% of total billed charges,4888.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5214.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1123.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2933.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4562.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3911.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2477.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4562.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3128.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6518.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.45,6518.5,
MESH KUGEL COMPOSIX 6 X 12,3620093,CDM,278,RC,C1781,HCPCS,Outpatient,,,2868.5,1721.1,,,,,,Other,Not Separately reimbursable,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2007.95,70,,,percent of total billed charges,70% of total billed charges,2151.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2294.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2868.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,494.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2007.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1721.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1090.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2007.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1376.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2868.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,449.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.49,2868.5,
BLADE ELECTRODE,3620101,CDM,272,RC,,,Outpatient,,,408.5,245.1,,,,,,Other,Not Separately reimbursable,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.25,50,,,percent of total billed charges,pays at 50% of total billed charges,285.95,70,,,percent of total billed charges,70% of total billed charges,306.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,326.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,285.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,285.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.01,367.65,
PLATE LISS,3620107,CDM,278,RC,C1713,HCPCS,Outpatient,,,2278,1366.8,,,,,,Other,Not Separately reimbursable,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1594.6,70,,,percent of total billed charges,70% of total billed charges,1708.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1822.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2278,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,392.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1025.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1594.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1366.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,865.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1594.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2278,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.96,2278,
CLAMP 4H,3620110,CDM,272,RC,,,Outpatient,,,615.5,369.3,,,,,,Other,Not Separately reimbursable,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.75,50,,,percent of total billed charges,pays at 50% of total billed charges,430.85,70,,,percent of total billed charges,70% of total billed charges,461.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,492.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,430.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,369.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,233.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,430.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.45,553.95,
CLAMP TUBE TO TUBE,3620111,CDM,278,RC,C1713,HCPCS,Outpatient,,,993.5,596.1,,,,,,Other,Not Separately reimbursable,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.45,70,,,percent of total billed charges,70% of total billed charges,745.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,794.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,993.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,171.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,695.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,596.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,695.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,993.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.68,993.5,
VISCERA RETAINERS,3620114,CDM,272,RC,,,Outpatient,,,81,48.6,,,,,,Other,Not Separately reimbursable,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,72.9,
BLADE TURBINATE INFERIOR,3620115,CDM,272,RC,,,Outpatient,,,358,214.8,,,,,,Other,Not Separately reimbursable,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179,50,,,percent of total billed charges,pays at 50% of total billed charges,250.6,70,,,percent of total billed charges,70% of total billed charges,268.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,286.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,250.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,250.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.1,322.2,
GRAFT DISTAFLO FLEX 6X80,3620116,CDM,278,RC,C1768,HCPCS,Outpatient,,,2844.5,1706.7,,,,,,Other,Not Separately reimbursable,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1991.15,70,,,percent of total billed charges,70% of total billed charges,2133.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2275.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2844.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,490.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1991.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1706.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1080.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1991.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2844.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.73,2844.5,
INTUBATION SET,3620128,CDM,272,RC,,,Outpatient,,,234,140.4,,,,,,Other,Not Separately reimbursable,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117,50,,,percent of total billed charges,pays at 50% of total billed charges,163.8,70,,,percent of total billed charges,70% of total billed charges,175.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,187.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,163.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.67,210.6,
TIBIAL INSERT,3620133,CDM,278,RC,C1713,HCPCS,Outpatient,,,1712.5,1027.5,,,,,,Other,Not Separately reimbursable,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.75,70,,,percent of total billed charges,70% of total billed charges,1284.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1370,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1712.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,295.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1198.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1027.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,650.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1198.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1712.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.35,1712.5,
PIN HINGED,3620136,CDM,278,RC,C1713,HCPCS,Outpatient,,,775,465,,,,,,Other,Not Separately reimbursable,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.5,70,,,percent of total billed charges,70% of total billed charges,581.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,542.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,465,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,542.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,775,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.44,775,
TIBIAL INSERT HINGED,3620137,CDM,278,RC,C1776,HCPCS,Outpatient,,,4965,2979,,,,,,Other,Not Separately reimbursable,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3475.5,70,,,percent of total billed charges,70% of total billed charges,3723.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4965,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,855.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2234.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3475.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2979,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1886.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3475.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2383.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4965,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,778.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.02,4965,
SPHERE REFLECT MARKER,3620143,CDM,272,RC,,,Outpatient,,,143,85.8,,,,,,Other,Not Separately reimbursable,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.5,50,,,percent of total billed charges,pays at 50% of total billed charges,100.1,70,,,percent of total billed charges,70% of total billed charges,107.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,128.7,
PATELLA LO PROFILE,3620149,CDM,278,RC,C1713,HCPCS,Outpatient,,,1526.5,915.9,,,,,,Other,Not Separately reimbursable,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.55,70,,,percent of total billed charges,70% of total billed charges,1144.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1221.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1526.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,263.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1068.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,580.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1068.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1526.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.2,1526.5,
MESH KUGEL MED OVAL,3620195,CDM,278,RC,C1781,HCPCS,Outpatient,,,1954,1172.4,,,,,,Other,Not Separately reimbursable,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1367.8,70,,,percent of total billed charges,70% of total billed charges,1465.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1563.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1954,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,336.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1367.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1172.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,742.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1367.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1954,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.19,1954,
ANCHOR SUTURE SPIRALOK,3620201,CDM,278,RC,C1713,HCPCS,Outpatient,,,506,303.6,,,,,,Other,Not Separately reimbursable,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.2,70,,,percent of total billed charges,70% of total billed charges,379.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,506,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.29,506,
DRILL DISP,3620205,CDM,272,RC,,,Outpatient,,,440,264,,,,,,Other,Not Separately reimbursable,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220,50,,,percent of total billed charges,pays at 50% of total billed charges,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.95,396,
DRILL BIT,3620207,CDM,272,RC,,,Outpatient,,,228,136.8,,,,,,Other,Not Separately reimbursable,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,205.2,
KIT HICKMAN CATH REPAIR,3620221,CDM,272,RC,,,Outpatient,,,202.5,121.5,,,,,,Other,Not Separately reimbursable,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.25,50,,,percent of total billed charges,pays at 50% of total billed charges,141.75,70,,,percent of total billed charges,70% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.73,182.25,
TIBIAL SPACER,3620225,CDM,278,RC,C1776,HCPCS,Outpatient,,,1312,787.2,,,,,,Other,Not Separately reimbursable,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,918.4,70,,,percent of total billed charges,70% of total billed charges,984,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1049.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1312,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,226.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,918.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,787.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,498.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,918.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1312,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.59,1312,
RADIAL HEAD STEM,3620227,CDM,278,RC,C1776,HCPCS,Outpatient,,,2666,1599.6,,,,,,Other,Not Separately reimbursable,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1866.2,70,,,percent of total billed charges,70% of total billed charges,1999.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2666,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,459.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1199.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1866.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1599.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1013.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1866.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2666,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.76,2666,
STEM RADIAL,3620228,CDM,278,RC,C1776,HCPCS,Outpatient,,,3515.2,2109.12,,,,,,Other,Not Separately reimbursable,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2460.64,70,,,percent of total billed charges,70% of total billed charges,2636.4,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2812.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3515.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,605.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1581.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2460.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2109.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1335.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2460.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1687.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3515.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.83,3515.2,
SCREW MILAGRO,3620243,CDM,278,RC,C1713,HCPCS,Outpatient,,,480,288,,,,,,Other,Not Separately reimbursable,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,70,,,percent of total billed charges,70% of total billed charges,360,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,480,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.22,480,
FEMORAL SLEEVE,3620245,CDM,278,RC,C1776,HCPCS,Outpatient,,,1744,1046.4,,,,,,Other,Not Separately reimbursable,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1220.8,70,,,percent of total billed charges,70% of total billed charges,1308,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1744,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.28,1744,
CATH CHOLANGIOGRAM,3620506,CDM,272,RC,,,Outpatient,,,90,54,,,,,,Other,Not Separately reimbursable,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,50,,,percent of total billed charges,pays at 50% of total billed charges,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,81,
KIT CMPRHNSV LAP COMMN BILE DUCT EXPLR,3620509,CDM,272,RC,,,Outpatient,,,814,488.4,,,,,,Other,Not Separately reimbursable,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407,50,,,percent of total billed charges,pays at 50% of total billed charges,569.8,70,,,percent of total billed charges,70% of total billed charges,610.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,651.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,569.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,569.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,732.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.55,732.6,
CATH EMBOLECTOMY,3620510,CDM,272,RC,C1757,HCPCS,Outpatient,,,165,99,,,,,,Other,Not Separately reimbursable,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.86,148.5,
CATH PRUITT,3620540,CDM,272,RC,,,Outpatient,,,149,89.4,,,,,,Other,Not Separately reimbursable,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.5,50,,,percent of total billed charges,pays at 50% of total billed charges,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,134.1,
CATH VENTRICULAR CSF,3620599,CDM,278,RC,C1729,HCPCS,Outpatient,,,169,101.4,,,,,,Other,Not Separately reimbursable,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.3,70,,,percent of total billed charges,70% of total billed charges,126.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
GRAFT VASCULAR,3620630,CDM,278,RC,C1768,HCPCS,Outpatient,,,1176,705.6,,,,,,Other,Not Separately reimbursable,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.2,70,,,percent of total billed charges,70% of total billed charges,882,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,940.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,202.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,823.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,823.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1176,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.28,1176,
GRAFT VASCULAR ST,3620755,CDM,278,RC,C1768,HCPCS,Outpatient,,,1025,615,,,,,,Other,Not Separately reimbursable,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.5,70,,,percent of total billed charges,70% of total billed charges,768.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1025,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,717.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,615,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,389.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,717.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.62,1025,
GRAFT VASCULAR,3620760,CDM,278,RC,C1768,HCPCS,Outpatient,,,1090,654,,,,,,Other,Not Separately reimbursable,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763,70,,,percent of total billed charges,70% of total billed charges,817.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,763,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,654,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,763,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1090,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.8,1090,
KIT BONE HARVESTING RIA,3620761,CDM,272,RC,,,Outpatient,,,3666,2199.6,,,,,,Other,Not Separately reimbursable,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833,50,,,percent of total billed charges,pays at 50% of total billed charges,2566.2,70,,,percent of total billed charges,70% of total billed charges,2749.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2932.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2804.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1649.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2566.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2199.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1393.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2566.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1759.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3299.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,574.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.46,3299.4,
REAMER HEAD RIA,3620762,CDM,272,RC,,,Outpatient,,,897,538.2,,,,,,Other,Not Separately reimbursable,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.5,50,,,percent of total billed charges,pays at 50% of total billed charges,627.9,70,,,percent of total billed charges,70% of total billed charges,672.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,717.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,627.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,538.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,627.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,807.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.56,807.3,
DURAMATRIX SUTURABLE,3620763,CDM,278,RC,C1763,HCPCS,Outpatient,,,627,376.2,,,,,,Other,Not Separately reimbursable,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.9,70,,,percent of total billed charges,70% of total billed charges,470.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,501.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,438.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,438.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,627,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.25,627,
NAIL HUMERUS,3620764,CDM,278,RC,C1713,HCPCS,Outpatient,,,3637,2182.2,,,,,,Other,Not Separately reimbursable,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2545.9,70,,,percent of total billed charges,70% of total billed charges,2727.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2909.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3637,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,626.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2545.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2182.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1382.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2545.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1745.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3637,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,569.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.92,3637,
BLADE HELICAL SCREW,3620766,CDM,278,RC,C1713,HCPCS,Outpatient,,,1389,833.4,,,,,,Other,Not Separately reimbursable,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,972.3,70,,,percent of total billed charges,70% of total billed charges,1041.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1389,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,239.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,972.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,833.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,527.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,972.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1389,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,217.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.66,1389,
NAIL TFN TI CANN,3620767,CDM,278,RC,C1713,HCPCS,Outpatient,,,4429,2657.4,,,,,,Other,Not Separately reimbursable,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3100.3,70,,,percent of total billed charges,70% of total billed charges,3321.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3543.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4429,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,763.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1993.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3100.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2657.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1683.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3100.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2125.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.02,4429,
GRAFT STD WALL,3620805,CDM,278,RC,C1768,HCPCS,Outpatient,,,1635,981,,,,,,Other,Not Separately reimbursable,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1144.5,70,,,percent of total billed charges,70% of total billed charges,1226.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1308,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1635,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,281.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1144.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,981,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,621.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1144.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1635,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.2,1635,
GRAFT STD WALL,3620810,CDM,278,RC,C1768,HCPCS,Outpatient,,,1629.5,977.7,,,,,,Other,Not Separately reimbursable,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1140.65,70,,,percent of total billed charges,70% of total billed charges,1222.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1303.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1629.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,280.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1140.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,977.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,619.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1140.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1629.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.34,1629.5,
GRAFT VASCULAR BIF,3620840,CDM,278,RC,C1768,HCPCS,Outpatient,,,1495,897,,,,,,Other,Not Separately reimbursable,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.5,70,,,percent of total billed charges,70% of total billed charges,1121.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1495,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1046.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1046.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1495,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.27,1495,
GRAFT VASCULAR BIF,3620850,CDM,278,RC,C1768,HCPCS,Outpatient,,,1910,1146,,,,,,Other,Not Separately reimbursable,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1337,70,,,percent of total billed charges,70% of total billed charges,1432.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1528,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1910,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,329.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,859.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1337,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1146,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,725.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1337,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,916.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1910,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,299.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.3,1910,
FREEZE DRIED ACHILLES,3620921,CDM,278,RC,,,Outpatient,,,1906,1143.6,,,,,,Other,Not Separately reimbursable,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953,50,,,percent of total billed charges,pays at 50% of total billed charges,1334.2,70,,,percent of total billed charges,70% of total billed charges,1429.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1524.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1906,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1334.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,724.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1334.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,914.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1906,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.67,1906,
TEFLON FELT,3620922,CDM,272,RC,C1768,HCPCS,Outpatient,,,179.5,107.7,,,,,,Other,Not Separately reimbursable,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.65,70,,,percent of total billed charges,70% of total billed charges,134.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,143.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,125.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.13,161.55,
KIT ABLATION PROBE,3620923,CDM,272,RC,,,Outpatient,,,6770,4062,,,,,,Other,Not Separately reimbursable,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3385,50,,,percent of total billed charges,pays at 50% of total billed charges,4739,70,,,percent of total billed charges,70% of total billed charges,5077.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5179.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3046.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4739,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4062,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2572.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4739,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6093,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1060.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1060.86,6093,
PATCH CARDIOVASCULAR,3620924,CDM,278,RC,C1768,HCPCS,Outpatient,,,1145,687,,,,,,Other,Not Separately reimbursable,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.5,70,,,percent of total billed charges,70% of total billed charges,858.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,197.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,801.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,687,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,435.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,801.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1145,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.42,1145,
FABRIC CARDIOVASCULAR,3620925,CDM,278,RC,C1768,HCPCS,Outpatient,,,364.5,218.7,,,,,,Other,Not Separately reimbursable,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.15,70,,,percent of total billed charges,70% of total billed charges,273.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,291.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,255.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.12,364.5,
GRAFT VASCULAR,3620929,CDM,278,RC,C1768,HCPCS,Outpatient,,,1618,970.8,,,,,,Other,Not Separately reimbursable,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1132.6,70,,,percent of total billed charges,70% of total billed charges,1213.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1618,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,278.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1132.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,970.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,614.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1132.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,776.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1618,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.54,1618,
GRASPER SUTURE,3621021,CDM,272,RC,,,Outpatient,,,283.5,170.1,,,,,,Other,Not Separately reimbursable,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,50,,,percent of total billed charges,pays at 50% of total billed charges,198.45,70,,,percent of total billed charges,70% of total billed charges,212.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,255.15,
GRASPER SUTURE,3621022,CDM,272,RC,,,Outpatient,,,378,226.8,,,,,,Other,Not Separately reimbursable,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,50,,,percent of total billed charges,pays at 50% of total billed charges,264.6,70,,,percent of total billed charges,70% of total billed charges,283.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,264.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,264.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.23,340.2,
BLADE AGEE CARPAL TUNNEL,3621025,CDM,272,RC,,,Outpatient,,,676,405.6,,,,,,Other,Not Separately reimbursable,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338,50,,,percent of total billed charges,pays at 50% of total billed charges,473.2,70,,,percent of total billed charges,70% of total billed charges,507,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,540.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,473.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,405.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,473.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,608.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.93,608.4,
BUR DIAMOND,3621029,CDM,272,RC,,,Outpatient,,,49.5,29.7,,,,,,Other,Not Separately reimbursable,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,44.55,
BIOPUMP,3621040,CDM,272,RC,,,Outpatient,,,541,324.6,,,,,,Other,Not Separately reimbursable,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.5,50,,,percent of total billed charges,pays at 50% of total billed charges,378.7,70,,,percent of total billed charges,70% of total billed charges,405.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,432.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,378.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,324.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,378.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.77,486.9,
CATHETER SET LV ASSIST,3621062,CDM,272,RC,,,Outpatient,,,36400,21840,,,,,,Other,Not Separately reimbursable,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18200,50,,,percent of total billed charges,pays at 50% of total billed charges,25480,70,,,percent of total billed charges,70% of total billed charges,27300,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,29120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27846,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16380,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13832,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,25480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17472,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32760,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5703.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5703.88,32760,
CATH ANGIOGRAPHY,3621063,CDM,272,RC,,,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,68.9,
CATHETER SET LV ASSIST,3621064,CDM,272,RC,,,Outpatient,,,58500,35100,,,,,,Other,Not Separately reimbursable,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29250,50,,,percent of total billed charges,pays at 50% of total billed charges,40950,70,,,percent of total billed charges,70% of total billed charges,43875,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,46800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44752.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26325,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40950,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35100,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22230,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,40950,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28080,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52650,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9166.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9166.95,52650,
CANNULA AORTIC,3621070,CDM,272,RC,,,Outpatient,,,92.5,55.5,,,,,,Other,Not Separately reimbursable,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.25,50,,,percent of total billed charges,pays at 50% of total billed charges,64.75,70,,,percent of total billed charges,70% of total billed charges,69.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,83.25,
CANNULA AORTIC ARCH,3621075,CDM,272,RC,,,Outpatient,,,126,75.6,,,,,,Other,Not Separately reimbursable,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,50,,,percent of total billed charges,pays at 50% of total billed charges,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,113.4,
CANNULA AORTIC,3621085,CDM,272,RC,,,Outpatient,,,76.5,45.9,,,,,,Other,Not Separately reimbursable,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,50,,,percent of total billed charges,pays at 50% of total billed charges,53.55,70,,,percent of total billed charges,70% of total billed charges,57.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,68.85,
CANNULA ARTERIAL,3621095,CDM,272,RC,,,Outpatient,,,77.5,46.5,,,,,,Other,Not Separately reimbursable,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.75,50,,,percent of total billed charges,pays at 50% of total billed charges,54.25,70,,,percent of total billed charges,70% of total billed charges,58.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,69.75,
CANNULA CORONARY,3621115,CDM,272,RC,,,Outpatient,,,56.5,33.9,,,,,,Other,Not Separately reimbursable,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,50,,,percent of total billed charges,pays at 50% of total billed charges,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,50.85,
CANNULA FEM VENOUS,3621155,CDM,272,RC,,,Outpatient,,,272,163.2,,,,,,Other,Not Separately reimbursable,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136,50,,,percent of total billed charges,pays at 50% of total billed charges,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,244.8,
CANNULA VENOUS,3621171,CDM,272,RC,,,Outpatient,,,89.5,53.7,,,,,,Other,Not Separately reimbursable,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.75,50,,,percent of total billed charges,pays at 50% of total billed charges,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,80.55,
CANNULA RETROPLEGIA,3621175,CDM,272,RC,,,Outpatient,,,249,149.4,,,,,,Other,Not Separately reimbursable,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.5,50,,,percent of total billed charges,pays at 50% of total billed charges,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.02,224.1,
CANNULA CARDIOPLEGIA RETROGRADE,3621184,CDM,272,RC,,,Outpatient,,,474.45,284.67,,,,,,Other,Not Separately reimbursable,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.23,50,,,percent of total billed charges,pays at 50% of total billed charges,332.12,70,,,percent of total billed charges,70% of total billed charges,355.84,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,379.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,332.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,427.01,
CANNULA RETROPLEGIA,3621185,CDM,272,RC,,,Outpatient,,,214,128.4,,,,,,Other,Not Separately reimbursable,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107,50,,,percent of total billed charges,pays at 50% of total billed charges,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,192.6,
CATH VENOUS RETURN 32FR,3621384,CDM,272,RC,,,Outpatient,,,84,50.4,,,,,,Other,Not Separately reimbursable,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,50,,,percent of total billed charges,pays at 50% of total billed charges,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,75.6,
CONNECTOR BYPASS,3621508,CDM,272,RC,,,Outpatient,,,20,12,,,,,,Other,Not Separately reimbursable,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,18,
MCGEE PISTON,3621629,CDM,272,RC,,,Outpatient,,,216.5,129.9,,,,,,Other,Not Separately reimbursable,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.25,50,,,percent of total billed charges,pays at 50% of total billed charges,151.55,70,,,percent of total billed charges,70% of total billed charges,162.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.93,194.85,
LEADS PACING,3621630,CDM,275,RC,,,Outpatient,,,96.5,57.9,,,,,,Other,Not Separately reimbursable,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.25,50,,,percent of total billed charges,pays at 50% of total billed charges,67.55,70,,,percent of total billed charges,70% of total billed charges,72.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,86.85,
LEAD EPICARDIAL,3621631,CDM,278,RC,C1896,HCPCS,Outpatient,,,1235,741,,,,,,Other,Not Separately reimbursable,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864.5,70,,,percent of total billed charges,70% of total billed charges,926.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,988,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,212.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.52,1235,
LEAD IMPLANT TOOL,3621632,CDM,272,RC,,,Outpatient,,,1235,741,,,,,,Other,Not Separately reimbursable,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.5,50,,,percent of total billed charges,pays at 50% of total billed charges,864.5,70,,,percent of total billed charges,70% of total billed charges,926.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,988,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1111.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.52,1111.5,
LEAD BIPOLAR ADAPTER,3621633,CDM,272,RC,,,Outpatient,,,375,225,,,,,,Other,Not Separately reimbursable,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,50,,,percent of total billed charges,pays at 50% of total billed charges,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,337.5,
KIT PIN PLUG,3621634,CDM,278,RC,C1882,HCPCS,Outpatient,,,150,90,,,,,,Other,Not Separately reimbursable,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
ENDCAP PACING LEAD,3621635,CDM,278,RC,,,Outpatient,,,48,28.8,,,,,,Other,Not Separately reimbursable,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,50,,,percent of total billed charges,pays at 50% of total billed charges,33.6,70,,,percent of total billed charges,70% of total billed charges,36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,48,
INSERT SOFT FIBER,3621637,CDM,272,RC,,,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30,50,,,percent of total billed charges,pays at 50% of total billed charges,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,54,
STOPCOCK 4 WAY,3621638,CDM,272,RC,,,Outpatient,,,9.5,5.7,,,,,,Other,Not Separately reimbursable,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,8.55,
TUBING PRESSURE,3621640,CDM,272,RC,,,Outpatient,,,18,10.8,,,,,,Other,Not Separately reimbursable,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,16.2,
HEART PUNCH AORTIC 2.7,3621643,CDM,272,RC,,,Outpatient,,,111.5,66.9,,,,,,Other,Not Separately reimbursable,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.75,50,,,percent of total billed charges,pays at 50% of total billed charges,78.05,70,,,percent of total billed charges,70% of total billed charges,83.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,89.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.47,100.35,
PUNCH AORTIC 4.5,3621655,CDM,272,RC,,,Outpatient,,,113.5,68.1,,,,,,Other,Not Separately reimbursable,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.75,50,,,percent of total billed charges,pays at 50% of total billed charges,79.45,70,,,percent of total billed charges,70% of total billed charges,85.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,90.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,79.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.79,102.15,
SUTURE HEART E-PK,3621682,CDM,272,RC,,,Outpatient,,,559.5,335.7,,,,,,Other,Not Separately reimbursable,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.75,50,,,percent of total billed charges,pays at 50% of total billed charges,391.65,70,,,percent of total billed charges,70% of total billed charges,419.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,447.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,391.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,335.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,391.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.67,503.55,
VALVE HEART AORTIC TISSUE,3621699,CDM,278,RC,,,Outpatient,,,11472.5,6883.5,,,,,,Other,Not Separately reimbursable,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5736.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8030.75,70,,,percent of total billed charges,70% of total billed charges,8604.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,9178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11472.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5162.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8030.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6883.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4359.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8030.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5506.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11472.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1797.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.74,11472.5,
GRAFT VALVED AORTIC,3621704,CDM,278,RC,C1768,HCPCS,Outpatient,,,7280,4368,,,,,,Other,Not Separately reimbursable,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5096,70,,,percent of total billed charges,70% of total billed charges,5460,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7280,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1254.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3276,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5096,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4368,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2766.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5096,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3494.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7280,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1140.78,7280,
VALVE HEART AORTIC MECH,3621705,CDM,278,RC,,,Outpatient,,,8774,5264.4,,,,,,Other,Not Separately reimbursable,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4387,50,,,percent of total billed charges,pays at 50% of total billed charges,6141.8,70,,,percent of total billed charges,70% of total billed charges,6580.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7019.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8774,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3948.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6141.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5264.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3334.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6141.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4211.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8774,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1374.89,8774,
ENDO BUTTON,3622994,CDM,278,RC,C1713,HCPCS,Outpatient,,,650,390,,,,,,Other,Not Separately reimbursable,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
KIT ORTHO CORE COMPRESSION,3622995,CDM,278,RC,C1713,HCPCS,Outpatient,,,8110.7,4866.42,,,,,,Other,Not Separately reimbursable,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5677.49,70,,,percent of total billed charges,70% of total billed charges,6083.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6488.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8110.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1397.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3649.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5677.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4866.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3082.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5677.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3893.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8110.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1270.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1270.95,8110.7,
KIT ORTHO STAPLE,3622996,CDM,278,RC,C1713,HCPCS,Outpatient,,,2803,1681.8,,,,,,Other,Not Separately reimbursable,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1962.1,70,,,percent of total billed charges,70% of total billed charges,2102.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2803,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1962.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1681.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1065.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1962.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2803,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.23,2803,
CATH URET,3623000,CDM,272,RC,C1758,HCPCS,Outpatient,,,147.15,88.29,,,,,,Other,Not Separately reimbursable,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.01,70,,,percent of total billed charges,70% of total billed charges,110.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,103.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,103.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.06,132.44,
CORD BIPOLAR FORCEP,3623102,CDM,272,RC,,,Outpatient,,,24,14.4,,,,,,Other,Not Separately reimbursable,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,21.6,
CORD CONNECTING BUGBY,3623105,CDM,272,RC,,,Outpatient,,,19,11.4,,,,,,Other,Not Separately reimbursable,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,17.1,
GLIDEWIRE .038,3623205,CDM,272,RC,C1769,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,54,
GLIDEWIRE .038,3623220,CDM,272,RC,C1769,HCPCS,Outpatient,,,126,75.6,,,,,,Other,Not Separately reimbursable,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,113.4,
GUIDEWIRE .032,3623270,CDM,272,RC,C1769,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
GUIDEWIRE .038,3623285,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,,,,,Other,Not Separately reimbursable,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,43.65,
LOOP CUTTING 24FR,3623360,CDM,272,RC,,,Outpatient,,,184,110.4,,,,,,Other,Not Separately reimbursable,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,165.6,
LOOP VESSEL,3623374,CDM,272,RC,,,Outpatient,,,32,19.2,,,,,,Other,Not Separately reimbursable,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16,50,,,percent of total billed charges,pays at 50% of total billed charges,22.4,70,,,percent of total billed charges,70% of total billed charges,24,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.01,28.8,
LOOPS VESSEL,3623375,CDM,272,RC,,,Outpatient,,,9.5,5.7,,,,,,Other,Not Separately reimbursable,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,8.55,
TOURNIQUET SET W SNARE VASCULAR,3623382,CDM,272,RC,,,Outpatient,,,15.15,9.09,,,,,,Other,Not Separately reimbursable,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.58,50,,,percent of total billed charges,pays at 50% of total billed charges,10.61,70,,,percent of total billed charges,70% of total billed charges,11.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,12.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.37,13.64,
SUTURE AID BOOTIES,3623385,CDM,272,RC,,,Outpatient,,,9.5,5.7,,,,,,Other,Not Separately reimbursable,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,8.55,
LOOP OSTOMY BRIDGE,3623390,CDM,272,RC,,,Outpatient,,,12.5,7.5,,,,,,Other,Not Separately reimbursable,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,11.25,
NDL BIOPTY CUT BIOPSY,3623400,CDM,272,RC,,,Outpatient,,,71.5,42.9,,,,,,Other,Not Separately reimbursable,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.75,50,,,percent of total billed charges,pays at 50% of total billed charges,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,64.35,
CATH PLUG,3623420,CDM,272,RC,,,Outpatient,,,2,1.2,,,,,,Other,Not Separately reimbursable,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,50,,,percent of total billed charges,pays at 50% of total billed charges,1.4,70,,,percent of total billed charges,70% of total billed charges,1.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.31,1.8,
IMPLANT URINARY SYNTHETIC 1ML,3623421,CDM,278,RC,L8606,HCPCS,Outpatient,,,942.5,565.5,,,,,,Other,Not Separately reimbursable,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.25,50,,,percent of total billed charges,pays at 50% of total billed charges,659.75,70,,,percent of total billed charges,70% of total billed charges,706.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,754,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,942.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,659.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,565.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,659.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,942.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.69,942.5,
IMPLNT SYNTHETIC MATERIAL 1ML VOCAL CORD,3623423,CDM,278,RC,C1878,HCPCS,Outpatient,,,747.5,448.5,,,,,,Other,Not Separately reimbursable,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.25,70,,,percent of total billed charges,70% of total billed charges,560.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,598,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,523.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,448.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,523.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,747.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.13,747.5,
IMPLANT VOCAL FOLD,3623425,CDM,278,RC,C1878,HCPCS,Outpatient,,,315,189,,,,,,Other,Not Separately reimbursable,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.5,70,,,percent of total billed charges,70% of total billed charges,236.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.36,315,
NEEDLE TRANSORAL,3623430,CDM,272,RC,,,Outpatient,,,97.5,58.5,,,,,,Other,Not Separately reimbursable,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.75,50,,,percent of total billed charges,pays at 50% of total billed charges,68.25,70,,,percent of total billed charges,70% of total billed charges,73.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,87.75,
RETRIEVAL STONE,3623475,CDM,272,RC,,,Outpatient,,,410.5,246.3,,,,,,Other,Not Separately reimbursable,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.25,50,,,percent of total billed charges,pays at 50% of total billed charges,287.35,70,,,percent of total billed charges,70% of total billed charges,307.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.33,369.45,
SYS URETERAL DILATION,3623520,CDM,272,RC,,,Outpatient,,,333,199.8,,,,,,Other,Not Separately reimbursable,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.5,50,,,percent of total billed charges,pays at 50% of total billed charges,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,299.7,
SET VASCULAR DILATOR,3623977,CDM,272,RC,,,Outpatient,,,88,52.8,,,,,,Other,Not Separately reimbursable,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44,50,,,percent of total billed charges,pays at 50% of total billed charges,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,79.2,
ABRADER,3624002,CDM,272,RC,,,Outpatient,,,180.5,108.3,,,,,,Other,Not Separately reimbursable,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.25,50,,,percent of total billed charges,pays at 50% of total billed charges,126.35,70,,,percent of total billed charges,70% of total billed charges,135.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,126.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.28,162.45,
ENDOSTAT 0.3,3624009,CDM,272,RC,,,Outpatient,,,704.5,422.7,,,,,,Other,Not Separately reimbursable,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.25,50,,,percent of total billed charges,pays at 50% of total billed charges,493.15,70,,,percent of total billed charges,70% of total billed charges,528.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,563.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,493.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,422.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,493.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,634.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.4,634.05,
ENDOSTAT,3624011,CDM,272,RC,,,Outpatient,,,474.5,284.7,,,,,,Other,Not Separately reimbursable,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.25,50,,,percent of total billed charges,pays at 50% of total billed charges,332.15,70,,,percent of total billed charges,70% of total billed charges,355.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,379.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,332.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.35,427.05,
SET ARTHROSCOPIC CANNULA,3624013,CDM,272,RC,,,Outpatient,,,70.5,42.3,,12.69,18,,,percent of total billed charges,pays at 18% of total charges,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.25,50,,,percent of total billed charges,pays at 50% of total billed charges,49.35,70,,,percent of total billed charges,70% of total billed charges,52.88,75,,,percent of total billed charges,75% of total billed charges,35.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.05,70.5,
SUTURE RETRIEVER,3624016,CDM,272,RC,,,Outpatient,,,112.5,67.5,,20.25,18,,,percent of total billed charges,pays at 18% of total charges,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,50,,,percent of total billed charges,pays at 50% of total billed charges,78.75,70,,,percent of total billed charges,70% of total billed charges,84.38,75,,,percent of total billed charges,75% of total billed charges,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,112.5,
BIOPLUG CEMENT RESTRICTOR,3624022,CDM,272,RC,,,Outpatient,,,1152,691.2,,207.36,18,,,percent of total billed charges,pays at 18% of total charges,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,576,50,,,percent of total billed charges,pays at 50% of total billed charges,806.4,70,,,percent of total billed charges,70% of total billed charges,864,75,,,percent of total billed charges,75% of total billed charges,576,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,921.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,691.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,881.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,806.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,691.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,437.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,806.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1036.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.52,1152,
BLADE CUTTER,3624029,CDM,272,RC,,,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.5,50,,,percent of total billed charges,pays at 50% of total billed charges,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
CEMENT RESTRICTOR,3624030,CDM,272,RC,,,Outpatient,,,610,366,,109.8,18,,,percent of total billed charges,pays at 18% of total charges,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,305,50,,,percent of total billed charges,pays at 50% of total billed charges,427,70,,,percent of total billed charges,70% of total billed charges,457.5,75,,,percent of total billed charges,75% of total billed charges,305,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,488,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,366,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,427,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,366,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,427,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,610,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,549,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.59,610,
STEM ULNAR,3624031,CDM,278,RC,C1776,HCPCS,Outpatient,,,10407,6244.2,,1873.26,18,,,percent of total billed charges,pays at 18% of total charges,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1873.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7284.9,70,,,percent of total billed charges,70% of total billed charges,7805.25,75,,,percent of total billed charges,75% of total billed charges,5203.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6244.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10407,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1793.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4683.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7284.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6244.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3954.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7284.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4995.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1630.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.78,10407,
BLADE FULL RADIUS,3624050,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
STEM ULNAR,3624051,CDM,278,RC,C1776,HCPCS,Outpatient,,,3900,2340,,702,18,,,percent of total billed charges,pays at 18% of total charges,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,70,,,percent of total billed charges,70% of total billed charges,2925,75,,,percent of total billed charges,75% of total billed charges,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,671.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1755,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1482,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.13,3900,
SUTURE PASSER,3624052,CDM,272,RC,,,Outpatient,,,975,585,,175.5,18,,,percent of total billed charges,pays at 18% of total charges,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.5,50,,,percent of total billed charges,pays at 50% of total billed charges,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,745.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,877.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
BLADE PATELLAR REAMING DI,3624089,CDM,272,RC,,,Outpatient,,,131.5,78.9,,23.67,18,,,percent of total billed charges,pays at 18% of total charges,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.75,50,,,percent of total billed charges,pays at 50% of total billed charges,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,65.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,131.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.61,131.5,
BLADE CUTTER,3624096,CDM,272,RC,,,Outpatient,,,231,138.6,,41.58,18,,,percent of total billed charges,pays at 18% of total charges,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.5,50,,,percent of total billed charges,pays at 50% of total billed charges,161.7,70,,,percent of total billed charges,70% of total billed charges,173.25,75,,,percent of total billed charges,75% of total billed charges,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,231,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,207.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.2,231,
BLADE BRN DERMATOME EC,3624130,CDM,272,RC,,,Outpatient,,,82,49.2,,14.76,18,,,percent of total billed charges,pays at 18% of total charges,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41,50,,,percent of total billed charges,pays at 50% of total billed charges,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,82,
SKIN GRAFT CARRIERS,3624132,CDM,272,RC,,,Outpatient,,,63,37.8,,11.34,18,,,percent of total billed charges,pays at 18% of total charges,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,50,,,percent of total billed charges,pays at 50% of total billed charges,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,63,
BUR,3624166,CDM,272,RC,,,Outpatient,,,63,37.8,,11.34,18,,,percent of total billed charges,pays at 18% of total charges,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,50,,,percent of total billed charges,pays at 50% of total billed charges,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,63,
BUR,3624168,CDM,272,RC,,,Outpatient,,,124,74.4,,22.32,18,,,percent of total billed charges,pays at 18% of total charges,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62,50,,,percent of total billed charges,pays at 50% of total billed charges,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,124,
CATH LEONARD DUAL,3624221,CDM,272,RC,,,Outpatient,,,509.5,305.7,,91.71,18,,,percent of total billed charges,pays at 18% of total charges,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.75,50,,,percent of total billed charges,pays at 50% of total billed charges,356.65,70,,,percent of total billed charges,70% of total billed charges,382.13,75,,,percent of total billed charges,75% of total billed charges,254.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,407.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,389.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,356.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,305.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,356.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,509.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,458.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.84,509.5,
BLADE SAW,3624222,CDM,272,RC,,,Outpatient,,,104,62.4,,18.72,18,,,percent of total billed charges,pays at 18% of total charges,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52,50,,,percent of total billed charges,pays at 50% of total billed charges,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,104,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,104,
BASE ATTACHMENT EXT FIXATOR,3624229,CDM,272,RC,,,Outpatient,,,2600,1560,,468,18,,,percent of total billed charges,pays at 18% of total charges,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1300,50,,,percent of total billed charges,pays at 50% of total billed charges,1820,70,,,percent of total billed charges,70% of total billed charges,1950,75,,,percent of total billed charges,75% of total billed charges,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1989,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,988,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2340,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.42,2600,
CATH PERITONEAL,3624250,CDM,278,RC,C1750,HCPCS,Outpatient,,,535.5,321.3,,96.39,18,,,percent of total billed charges,pays at 18% of total charges,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.85,70,,,percent of total billed charges,70% of total billed charges,401.63,75,,,percent of total billed charges,75% of total billed charges,267.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,428.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,374.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,374.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,535.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,535.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.91,535.5,
ADAPTER LG WIRE,3624251,CDM,272,RC,,,Outpatient,,,295,177,,53.1,18,,,percent of total billed charges,pays at 18% of total charges,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.5,50,,,percent of total billed charges,pays at 50% of total billed charges,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,147.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,295,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.23,295,
CATH VENTRICULAR,3624260,CDM,272,RC,,,Outpatient,,,188,112.8,,33.84,18,,,percent of total billed charges,pays at 18% of total charges,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94,50,,,percent of total billed charges,pays at 50% of total billed charges,131.6,70,,,percent of total billed charges,70% of total billed charges,141,75,,,percent of total billed charges,75% of total billed charges,94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,188,
RING MEDIUM,3624265,CDM,272,RC,,,Outpatient,,,1325,795,,238.5,18,,,percent of total billed charges,pays at 18% of total charges,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.5,50,,,percent of total billed charges,pays at 50% of total billed charges,927.5,70,,,percent of total billed charges,70% of total billed charges,993.75,75,,,percent of total billed charges,75% of total billed charges,662.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1060,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,795,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1013.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,927.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,795,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,927.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1192.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.63,1325,
CATH BROVIAC,3624280,CDM,272,RC,C1751,HCPCS,Outpatient,,,564,338.4,,101.52,18,,,percent of total billed charges,pays at 18% of total charges,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.8,70,,,percent of total billed charges,70% of total billed charges,423,75,,,percent of total billed charges,75% of total billed charges,282,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,451.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,338.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,431.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,97.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,394.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,338.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,394.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,564,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,507.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.38,564,
PLATE FOOT EXT FIXATOR,3624285,CDM,272,RC,,,Outpatient,,,3080,1848,,554.4,18,,,percent of total billed charges,pays at 18% of total charges,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,554.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1540,50,,,percent of total billed charges,pays at 50% of total billed charges,2156,70,,,percent of total billed charges,70% of total billed charges,2310,75,,,percent of total billed charges,75% of total billed charges,1540,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2356.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1848,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1478.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2772,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.64,3080,
STRUTS LONG EXT FIXATOR,3624287,CDM,272,RC,,,Outpatient,,,1344,806.4,,241.92,18,,,percent of total billed charges,pays at 18% of total charges,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,672,50,,,percent of total billed charges,pays at 50% of total billed charges,940.8,70,,,percent of total billed charges,70% of total billed charges,1008,75,,,percent of total billed charges,75% of total billed charges,672,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1075.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,806.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1028.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,940.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,806.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,940.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1344,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1209.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.6,1344,
CONNECTOR EXT FIXATOR,3624289,CDM,272,RC,,,Outpatient,,,96,57.6,,17.28,18,,,percent of total billed charges,pays at 18% of total charges,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48,50,,,percent of total billed charges,pays at 50% of total billed charges,67.2,70,,,percent of total billed charges,70% of total billed charges,72,75,,,percent of total billed charges,75% of total billed charges,48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,96,
CATH MAHURKAR,3624340,CDM,272,RC,C1752,HCPCS,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
CATH MONCRIEF,3624351,CDM,272,RC,C1750,HCPCS,Outpatient,,,593.5,356.1,,106.83,18,,,percent of total billed charges,pays at 18% of total charges,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.45,70,,,percent of total billed charges,70% of total billed charges,445.13,75,,,percent of total billed charges,75% of total billed charges,296.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,474.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,415.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,415.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,593.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,534.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93,593.5,
DEVICE VENTRICULAR ACCESS,3624450,CDM,278,RC,,,Outpatient,,,609,365.4,,109.62,18,,,percent of total billed charges,pays at 18% of total charges,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.5,50,,,percent of total billed charges,pays at 50% of total billed charges,426.3,70,,,percent of total billed charges,70% of total billed charges,456.75,75,,,percent of total billed charges,75% of total billed charges,304.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,365.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,609,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,426.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,365.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,426.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,609,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,609,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.43,609,
KIT VENTRICULAR PRESSURE,3624601,CDM,272,RC,,,Outpatient,,,1324,794.4,,238.32,18,,,percent of total billed charges,pays at 18% of total charges,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662,50,,,percent of total billed charges,pays at 50% of total billed charges,926.8,70,,,percent of total billed charges,70% of total billed charges,993,75,,,percent of total billed charges,75% of total billed charges,662,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1059.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,794.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1012.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,926.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,794.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,926.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1324,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1191.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.47,1324,
KIT ANDREWS FRAME,3624602,CDM,272,RC,,,Outpatient,,,135.5,81.3,,24.39,18,,,percent of total billed charges,pays at 18% of total charges,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.75,50,,,percent of total billed charges,pays at 50% of total billed charges,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,67.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,135.5,
KIT CRANIOPLASTIC,3624610,CDM,272,RC,,,Outpatient,,,1575,945,,283.5,18,,,percent of total billed charges,pays at 18% of total charges,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,283.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1102.5,70,,,percent of total billed charges,70% of total billed charges,1181.25,75,,,percent of total billed charges,75% of total billed charges,787.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,945,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1204.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,708.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1102.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,945,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,598.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1102.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1417.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.8,1575,
KIT INTRODUCER TRACH,3624640,CDM,272,RC,,,Outpatient,,,430,258,,77.4,18,,,percent of total billed charges,pays at 18% of total charges,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,215,50,,,percent of total billed charges,pays at 50% of total billed charges,301,70,,,percent of total billed charges,70% of total billed charges,322.5,75,,,percent of total billed charges,75% of total billed charges,215,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,301,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,430,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,387,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.38,430,
KIT INTRODUCER,3624642,CDM,272,RC,,,Outpatient,,,174.5,104.7,,31.41,18,,,percent of total billed charges,pays at 18% of total charges,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.25,50,,,percent of total billed charges,pays at 50% of total billed charges,122.15,70,,,percent of total billed charges,70% of total billed charges,130.88,75,,,percent of total billed charges,75% of total billed charges,87.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,174.5,
KIT SHOULDER CANNULA,3624670,CDM,272,RC,,,Outpatient,,,77.5,46.5,,13.95,18,,,percent of total billed charges,pays at 18% of total charges,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.75,50,,,percent of total billed charges,pays at 50% of total billed charges,54.25,70,,,percent of total billed charges,70% of total billed charges,58.13,75,,,percent of total billed charges,75% of total billed charges,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,77.5,
KIT SHOULDER SUSP DRAPE,3624671,CDM,272,RC,,,Outpatient,,,182.5,109.5,,32.85,18,,,percent of total billed charges,pays at 18% of total charges,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.25,50,,,percent of total billed charges,pays at 50% of total billed charges,127.75,70,,,percent of total billed charges,70% of total billed charges,136.88,75,,,percent of total billed charges,75% of total billed charges,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,182.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,164.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.6,182.5,
KIT UNIV CANNULA,3624680,CDM,272,RC,,,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
MESH MARLEX,3624767,CDM,278,RC,C1781,HCPCS,Outpatient,,,269,161.4,,48.42,18,,,percent of total billed charges,pays at 18% of total charges,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.3,70,,,percent of total billed charges,70% of total billed charges,201.75,75,,,percent of total billed charges,75% of total billed charges,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.15,269,
MESH TRELEX 2 X 12,3624803,CDM,278,RC,C1781,HCPCS,Outpatient,,,180.5,108.3,,32.49,18,,,percent of total billed charges,pays at 18% of total charges,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.35,70,,,percent of total billed charges,70% of total billed charges,135.38,75,,,percent of total billed charges,75% of total billed charges,90.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,126.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,180.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.28,180.5,
MESH TRELEX 10 X 14,3624805,CDM,278,RC,C1781,HCPCS,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,333,
MESH SURGIPRO 14 X 9,3624819,CDM,278,RC,C1781,HCPCS,Outpatient,,,510.5,306.3,,91.89,18,,,percent of total billed charges,pays at 18% of total charges,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.35,70,,,percent of total billed charges,70% of total billed charges,382.88,75,,,percent of total billed charges,75% of total billed charges,255.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,408.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,306.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,510.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,510.5,
MESH SURGIPRO 1 X 4,3624820,CDM,278,RC,C1781,HCPCS,Outpatient,,,118.5,71.1,,21.33,18,,,percent of total billed charges,pays at 18% of total charges,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.95,70,,,percent of total billed charges,70% of total billed charges,88.88,75,,,percent of total billed charges,75% of total billed charges,59.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,118.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,118.5,
MESH SURGIPRO 3 X 5,3624821,CDM,278,RC,C1781,HCPCS,Outpatient,,,182.5,109.5,,32.85,18,,,percent of total billed charges,pays at 18% of total charges,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.75,70,,,percent of total billed charges,70% of total billed charges,136.88,75,,,percent of total billed charges,75% of total billed charges,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,182.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,182.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.6,182.5,
PIN ORTHOSORB,3624881,CDM,278,RC,C1713,HCPCS,Outpatient,,,858,514.8,,154.44,18,,,percent of total billed charges,pays at 18% of total charges,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600.6,70,,,percent of total billed charges,70% of total billed charges,643.5,75,,,percent of total billed charges,75% of total billed charges,429,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,686.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,514.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,858,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,147.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,600.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,514.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,600.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,858,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,858,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.45,858,
GUIDEPIN DHS,3624882,CDM,272,RC,,,Outpatient,,,81,48.6,,14.58,18,,,percent of total billed charges,pays at 18% of total charges,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,81,
PIN HEWSON BREAK AWAY,3624890,CDM,278,RC,C1713,HCPCS,Outpatient,,,112.5,67.5,,20.25,18,,,percent of total billed charges,pays at 18% of total charges,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,70,,,percent of total billed charges,70% of total billed charges,84.38,75,,,percent of total billed charges,75% of total billed charges,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,112.5,
VITAL PORT PETITE,3624951,CDM,278,RC,C1788,HCPCS,Outpatient,,,992.5,595.5,,178.65,18,,,percent of total billed charges,pays at 18% of total charges,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.75,70,,,percent of total billed charges,70% of total billed charges,744.38,75,,,percent of total billed charges,75% of total billed charges,496.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,794,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,171.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,694.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,595.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,694.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,992.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,992.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.52,992.5,
RESERVOIR SALMON-RICKHAM,3625140,CDM,272,RC,,,Outpatient,,,347.5,208.5,,62.55,18,,,percent of total billed charges,pays at 18% of total charges,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.75,50,,,percent of total billed charges,pays at 50% of total billed charges,243.25,70,,,percent of total billed charges,70% of total billed charges,260.63,75,,,percent of total billed charges,75% of total billed charges,173.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,278,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,243.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,243.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,347.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,312.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.45,347.5,
RESERVOIR SALMON-RICKHAM,3625145,CDM,272,RC,,,Outpatient,,,377,226.2,,67.86,18,,,percent of total billed charges,pays at 18% of total charges,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.5,50,,,percent of total billed charges,pays at 50% of total billed charges,263.9,70,,,percent of total billed charges,70% of total billed charges,282.75,75,,,percent of total billed charges,75% of total billed charges,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,263.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,377,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,339.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.08,377,
SET CDIS IRRIGATION,3625175,CDM,272,RC,,,Outpatient,,,197.5,118.5,,35.55,18,,,percent of total billed charges,pays at 18% of total charges,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,98.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,197.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,197.5,
SET CHOLANGIOGRAPHY RABIN,3625221,CDM,272,RC,,,Outpatient,,,146,87.6,,26.28,18,,,percent of total billed charges,pays at 18% of total charges,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73,50,,,percent of total billed charges,pays at 50% of total billed charges,102.2,70,,,percent of total billed charges,70% of total billed charges,109.5,75,,,percent of total billed charges,75% of total billed charges,73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,102.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,146,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.88,146,
SET PUMP TUBE,3625240,CDM,272,RC,,,Outpatient,,,241.5,144.9,,43.47,18,,,percent of total billed charges,pays at 18% of total charges,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.75,50,,,percent of total billed charges,pays at 50% of total billed charges,169.05,70,,,percent of total billed charges,70% of total billed charges,181.13,75,,,percent of total billed charges,75% of total billed charges,120.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,169.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,241.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,217.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.84,241.5,
SET PUMP TUBE,3625242,CDM,272,RC,,,Outpatient,,,356,213.6,,64.08,18,,,percent of total billed charges,pays at 18% of total charges,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178,50,,,percent of total billed charges,pays at 50% of total billed charges,249.2,70,,,percent of total billed charges,70% of total billed charges,267,75,,,percent of total billed charges,75% of total billed charges,178,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,284.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,213.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,320.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.79,356,
SPLINT INTERNAL NASAL,3625270,CDM,272,RC,,,Outpatient,,,56.5,33.9,,10.17,18,,,percent of total billed charges,pays at 18% of total charges,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.25,50,,,percent of total billed charges,pays at 50% of total billed charges,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,56.5,
SPLINT INTERNAL NASAL,3625272,CDM,272,RC,,,Outpatient,,,44,26.4,,7.92,18,,,percent of total billed charges,pays at 18% of total charges,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22,50,,,percent of total billed charges,pays at 50% of total billed charges,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,44,
IMPLANT NASAL ABSORB,3625274,CDM,278,RC,L8699,HCPCS,Outpatient,,,1560,936,,280.8,18,,,percent of total billed charges,pays at 18% of total charges,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,780,50,,,percent of total billed charges,pays at 50% of total billed charges,1092,70,,,percent of total billed charges,70% of total billed charges,1170,75,,,percent of total billed charges,75% of total billed charges,780,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1560,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.45,1560,
SUTURE PASSER SM,3625300,CDM,272,RC,,,Outpatient,,,143,85.8,,25.74,18,,,percent of total billed charges,pays at 18% of total charges,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.5,50,,,percent of total billed charges,pays at 50% of total billed charges,100.1,70,,,percent of total billed charges,70% of total billed charges,107.25,75,,,percent of total billed charges,75% of total billed charges,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,143,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,128.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,143,
SUTURE PASSER,3625302,CDM,272,RC,,,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105,50,,,percent of total billed charges,pays at 50% of total billed charges,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
SUTURE PASSER LGE,3625304,CDM,272,RC,,,Outpatient,,,158.5,95.1,,28.53,18,,,percent of total billed charges,pays at 18% of total charges,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.25,50,,,percent of total billed charges,pays at 50% of total billed charges,110.95,70,,,percent of total billed charges,70% of total billed charges,118.88,75,,,percent of total billed charges,75% of total billed charges,79.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.84,158.5,
SUTURE RETRIEVER,3625306,CDM,272,RC,,,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44,50,,,percent of total billed charges,pays at 50% of total billed charges,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
TUBE VENT PE,3625350,CDM,272,RC,,,Outpatient,,,33.5,20.1,,6.03,18,,,percent of total billed charges,pays at 18% of total charges,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.75,50,,,percent of total billed charges,pays at 50% of total billed charges,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,16.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,33.5,
TUBE VENT PE,3625354,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
TUBE VENT PE,3625356,CDM,272,RC,,,Outpatient,,,73.5,44.1,,13.23,18,,,percent of total billed charges,pays at 18% of total charges,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,50,,,percent of total billed charges,pays at 50% of total billed charges,51.45,70,,,percent of total billed charges,70% of total billed charges,55.13,75,,,percent of total billed charges,75% of total billed charges,36.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,66.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,73.5,
TUBE VENT PE,3625372,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
TUBE VENT PE,3625378,CDM,272,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
WIRE SNARE,3625500,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
DRILL CANNULATED,3626695,CDM,272,RC,,,Outpatient,,,910,546,,163.8,18,,,percent of total billed charges,pays at 18% of total charges,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455,50,,,percent of total billed charges,pays at 50% of total billed charges,637,70,,,percent of total billed charges,70% of total billed charges,682.5,75,,,percent of total billed charges,75% of total billed charges,455,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,696.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,637,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,546,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,637,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,910,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,819,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.6,910,
VALVE HEART MITRAL MECH,3629006,CDM,278,RC,,,Outpatient,,,8774,5264.4,,1579.32,18,,,percent of total billed charges,pays at 18% of total charges,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1579.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4387,50,,,percent of total billed charges,pays at 50% of total billed charges,6141.8,70,,,percent of total billed charges,70% of total billed charges,6580.5,75,,,percent of total billed charges,75% of total billed charges,4387,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7019.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5264.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8774,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3948.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6141.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5264.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3334.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6141.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4211.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8774,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8774,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1374.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1374.89,8774,
PLATE LCP TI,3629011,CDM,278,RC,C1713,HCPCS,Outpatient,,,649,389.4,,116.82,18,,,percent of total billed charges,pays at 18% of total charges,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.3,70,,,percent of total billed charges,70% of total billed charges,486.75,75,,,percent of total billed charges,75% of total billed charges,324.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,519.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,389.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,649,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,454.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,389.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,454.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,649,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,649,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.7,649,
GRAFT VENAFLO,3629012,CDM,278,RC,C1768,HCPCS,Outpatient,,,1190.5,714.3,,214.29,18,,,percent of total billed charges,pays at 18% of total charges,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,833.35,70,,,percent of total billed charges,70% of total billed charges,892.88,75,,,percent of total billed charges,75% of total billed charges,595.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,952.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,714.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1190.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,833.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,714.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,452.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,833.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1190.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1190.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.55,1190.5,
BIOGLUE ADHESIVE,3629018,CDM,272,RC,,,Outpatient,,,1175,705,,211.5,18,,,percent of total billed charges,pays at 18% of total charges,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,211.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,587.5,50,,,percent of total billed charges,pays at 50% of total billed charges,822.5,70,,,percent of total billed charges,70% of total billed charges,881.25,75,,,percent of total billed charges,75% of total billed charges,587.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,940,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,705,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,898.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,822.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,822.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1175,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1057.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.12,1175,
PLUME AWAY LAP SMOKE EVAC,3629021,CDM,272,RC,,,Outpatient,,,54.5,32.7,,9.81,18,,,percent of total billed charges,pays at 18% of total charges,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.25,50,,,percent of total billed charges,pays at 50% of total billed charges,38.15,70,,,percent of total billed charges,70% of total billed charges,40.88,75,,,percent of total billed charges,75% of total billed charges,27.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,54.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.54,54.5,
SCREW LCKG 5.5,3629028,CDM,278,RC,C1713,HCPCS,Outpatient,,,231,138.6,,41.58,18,,,percent of total billed charges,pays at 18% of total charges,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.7,70,,,percent of total billed charges,70% of total billed charges,173.25,75,,,percent of total billed charges,75% of total billed charges,115.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,184.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,161.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,231,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,231,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.2,231,
SCREW CANCEL'S 6.5 X 45MM,3629761,CDM,278,RC,C1713,HCPCS,Outpatient,,,201.5,120.9,,36.27,18,,,percent of total billed charges,pays at 18% of total charges,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.05,70,,,percent of total billed charges,70% of total billed charges,151.13,75,,,percent of total billed charges,75% of total billed charges,100.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,201.5,
SCREW CANN 7.0,3629771,CDM,278,RC,C1713,HCPCS,Outpatient,,,418,250.8,,75.24,18,,,percent of total billed charges,pays at 18% of total charges,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,209,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,418,
SCREW COMPRESSION DHS,3629779,CDM,278,RC,C1713,HCPCS,Outpatient,,,77.5,46.5,,13.95,18,,,percent of total billed charges,pays at 18% of total charges,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.25,70,,,percent of total billed charges,70% of total billed charges,58.13,75,,,percent of total billed charges,75% of total billed charges,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,77.5,
SCREW BONE 20MM,3629791,CDM,278,RC,C1713,HCPCS,Outpatient,,,175.5,105.3,,31.59,18,,,percent of total billed charges,pays at 18% of total charges,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,70,,,percent of total billed charges,70% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,87.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,175.5,
SCREW BONE,3629828,CDM,278,RC,C1713,HCPCS,Outpatient,,,316,189.6,,56.88,18,,,percent of total billed charges,pays at 18% of total charges,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.2,70,,,percent of total billed charges,70% of total billed charges,237,75,,,percent of total billed charges,75% of total billed charges,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,316,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,316,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.52,316,
MEDULLARY VENT TUBING,3629839,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
SCREW LAG 110MM,3629922,CDM,278,RC,C1713,HCPCS,Outpatient,,,425.5,255.3,,76.59,18,,,percent of total billed charges,pays at 18% of total charges,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.85,70,,,percent of total billed charges,70% of total billed charges,319.13,75,,,percent of total billed charges,75% of total billed charges,212.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,425.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,425.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,425.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.68,425.5,
SCREW CORTEX 4.5 X 40 MM,3629991,CDM,278,RC,C1713,HCPCS,Outpatient,,,40,24,,7.2,18,,,percent of total billed charges,pays at 18% of total charges,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,70,,,percent of total billed charges,70% of total billed charges,30,75,,,percent of total billed charges,75% of total billed charges,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,40,
SHUNT CAROTID,3630001,CDM,272,RC,,,Outpatient,,,1143,685.8,,205.74,18,,,percent of total billed charges,pays at 18% of total charges,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,571.5,50,,,percent of total billed charges,pays at 50% of total billed charges,800.1,70,,,percent of total billed charges,70% of total billed charges,857.25,75,,,percent of total billed charges,75% of total billed charges,571.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,914.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,685.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,874.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,800.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,685.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,800.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1143,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1028.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,179.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.11,1143,
BLADE DUAL KAHOOK DISP,3630012,CDM,272,RC,,,Outpatient,,,507,304.2,,91.26,18,,,percent of total billed charges,pays at 18% of total charges,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.5,50,,,percent of total billed charges,pays at 50% of total billed charges,354.9,70,,,percent of total billed charges,70% of total billed charges,380.25,75,,,percent of total billed charges,75% of total billed charges,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,507,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,456.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.45,507,
PLATE CERVICAL,3630013,CDM,278,RC,C1713,HCPCS,Outpatient,,,4082,2449.2,,734.76,18,,,percent of total billed charges,pays at 18% of total charges,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,734.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2857.4,70,,,percent of total billed charges,70% of total billed charges,3061.5,75,,,percent of total billed charges,75% of total billed charges,2041,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2449.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4082,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,703.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2857.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2449.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1551.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2857.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1959.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4082,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4082,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,639.65,4082,
ACETABULAR LINER,3630014,CDM,278,RC,C1776,HCPCS,Outpatient,,,1072.5,643.5,,193.05,18,,,percent of total billed charges,pays at 18% of total charges,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.75,70,,,percent of total billed charges,70% of total billed charges,804.38,75,,,percent of total billed charges,75% of total billed charges,536.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,858,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,643.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1072.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,184.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,750.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,643.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,407.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,750.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1072.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1072.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.06,1072.5,
ACETABULAR LINER,3630015,CDM,278,RC,C1776,HCPCS,Outpatient,,,5980,3588,,1076.4,18,,,percent of total billed charges,pays at 18% of total charges,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1076.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4186,70,,,percent of total billed charges,70% of total billed charges,4485,75,,,percent of total billed charges,75% of total billed charges,2990,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3588,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5980,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1030.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2691,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4186,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3588,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2272.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4186,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2870.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5980,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5980,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,937.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.07,5980,
ACETABULAR BUTTRESS,3630016,CDM,278,RC,C1776,HCPCS,Outpatient,,,2831,1698.6,,509.58,18,,,percent of total billed charges,pays at 18% of total charges,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1981.7,70,,,percent of total billed charges,70% of total billed charges,2123.25,75,,,percent of total billed charges,75% of total billed charges,1415.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1698.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2831,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,487.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1273.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1981.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1698.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1075.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1981.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1358.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2831,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2831,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.62,2831,
KIT INSTRUMENT DISP,3630017,CDM,272,RC,,,Outpatient,,,666.25,399.75,,119.93,18,,,percent of total billed charges,pays at 18% of total charges,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.13,50,,,percent of total billed charges,pays at 50% of total billed charges,466.38,70,,,percent of total billed charges,70% of total billed charges,499.69,75,,,percent of total billed charges,75% of total billed charges,333.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,533,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,509.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,466.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,399.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,466.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,666.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,599.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,666.25,
RADIAL HEAD IMPLANT,3630018,CDM,278,RC,C1776,HCPCS,Outpatient,,,6662.5,3997.5,,1199.25,18,,,percent of total billed charges,pays at 18% of total charges,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1199.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4663.75,70,,,percent of total billed charges,70% of total billed charges,4996.88,75,,,percent of total billed charges,75% of total billed charges,3331.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5330,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3997.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6662.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1147.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2998.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4663.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3997.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2531.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4663.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3198,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1044.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.01,6662.5,
MENICUS ARROW,3630044,CDM,278,RC,C1713,HCPCS,Outpatient,,,399,239.4,,71.82,18,,,percent of total billed charges,pays at 18% of total charges,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.3,70,,,percent of total billed charges,70% of total billed charges,299.25,75,,,percent of total billed charges,75% of total billed charges,199.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,319.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,399,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,279.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,279.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,399,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,399,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.52,399,
AMBU BAG,3630050,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
STAPLER HERNIA,3630057,CDM,272,RC,,,Outpatient,,,714,428.4,,128.52,18,,,percent of total billed charges,pays at 18% of total charges,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357,50,,,percent of total billed charges,pays at 50% of total billed charges,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,357,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,271.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,714,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.88,714,
BONE DRI SURG WICK,3630074,CDM,278,RC,,,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.5,50,,,percent of total billed charges,pays at 50% of total billed charges,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
DRILL BIT CANN XL,3630075,CDM,272,RC,,,Outpatient,,,748,448.8,,134.64,18,,,percent of total billed charges,pays at 18% of total charges,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,374,50,,,percent of total billed charges,pays at 50% of total billed charges,523.6,70,,,percent of total billed charges,70% of total billed charges,561,75,,,percent of total billed charges,75% of total billed charges,374,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,598.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,448.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,572.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,523.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,448.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,523.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,748,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,673.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.21,748,
GUIDE PIN,3630084,CDM,272,RC,,,Outpatient,,,269,161.4,,48.42,18,,,percent of total billed charges,pays at 18% of total charges,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.5,50,,,percent of total billed charges,pays at 50% of total billed charges,188.3,70,,,percent of total billed charges,70% of total billed charges,201.75,75,,,percent of total billed charges,75% of total billed charges,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,242.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.15,269,
CANNULA CLEAR,3630090,CDM,272,RC,,,Outpatient,,,71.5,42.9,,12.87,18,,,percent of total billed charges,pays at 18% of total charges,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.75,50,,,percent of total billed charges,pays at 50% of total billed charges,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,71.5,
SCREW LAG,3630100,CDM,278,RC,C1713,HCPCS,Outpatient,,,497.5,298.5,,89.55,18,,,percent of total billed charges,pays at 18% of total charges,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.25,70,,,percent of total billed charges,70% of total billed charges,373.13,75,,,percent of total billed charges,75% of total billed charges,248.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,398,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,497.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,348.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,497.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,497.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.96,497.5,
BANDAGE ACE,3630110,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
DRESSING TRANSPARENT,3630119,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
SHUNT CAROTID ARTERY,3630126,CDM,272,RC,,,Outpatient,,,389.5,233.7,,70.11,18,,,percent of total billed charges,pays at 18% of total charges,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.75,50,,,percent of total billed charges,pays at 50% of total billed charges,272.65,70,,,percent of total billed charges,70% of total billed charges,292.13,75,,,percent of total billed charges,75% of total billed charges,194.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,272.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.03,389.5,
SHUNT CAROTID,3630127,CDM,272,RC,,,Outpatient,,,805,483,,144.9,18,,,percent of total billed charges,pays at 18% of total charges,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,402.5,50,,,percent of total billed charges,pays at 50% of total billed charges,563.5,70,,,percent of total billed charges,70% of total billed charges,603.75,75,,,percent of total billed charges,75% of total billed charges,402.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,483,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,615.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,563.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,483,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,305.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,563.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,805,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,724.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.14,805,
SUTURE WIRE,3630128,CDM,272,RC,C1713,HCPCS,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
SUTURE GUIDE GABBAY-FRAT,3630129,CDM,272,RC,,,Outpatient,,,169,101.4,,30.42,18,,,percent of total billed charges,pays at 18% of total charges,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.5,50,,,percent of total billed charges,pays at 50% of total billed charges,118.3,70,,,percent of total billed charges,70% of total billed charges,126.75,75,,,percent of total billed charges,75% of total billed charges,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
MONTGOMERY STRAPS,3630130,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
WRAP COBAN 4,3630136,CDM,272,RC,,,Outpatient,,,14.5,8.7,,2.61,18,,,percent of total billed charges,pays at 18% of total charges,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.25,50,,,percent of total billed charges,pays at 50% of total billed charges,10.15,70,,,percent of total billed charges,70% of total billed charges,10.88,75,,,percent of total billed charges,75% of total billed charges,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,14.5,
WRAP COBAN 6,3630137,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
SCREW CORTEX 2.7,3630172,CDM,278,RC,C1713,HCPCS,Outpatient,,,56,33.6,,10.08,18,,,percent of total billed charges,pays at 18% of total charges,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,70,,,percent of total billed charges,70% of total billed charges,42,75,,,percent of total billed charges,75% of total billed charges,28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.78,56,
SCREW 3.5,3630190,CDM,278,RC,C1713,HCPCS,Outpatient,,,46.5,27.9,,8.37,18,,,percent of total billed charges,pays at 18% of total charges,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.55,70,,,percent of total billed charges,70% of total billed charges,34.88,75,,,percent of total billed charges,75% of total billed charges,23.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.29,46.5,
SCREW CANC 4.0,3630208,CDM,278,RC,C1713,HCPCS,Outpatient,,,52.5,31.5,,9.45,18,,,percent of total billed charges,pays at 18% of total charges,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,70,,,percent of total billed charges,70% of total billed charges,39.38,75,,,percent of total billed charges,75% of total billed charges,26.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.23,52.5,
SCREW CANC 70MM,3630272,CDM,278,RC,C1713,HCPCS,Outpatient,,,71.5,42.9,,12.87,18,,,percent of total billed charges,pays at 18% of total charges,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,71.5,
SCREW CANC 80MM,3630274,CDM,278,RC,C1713,HCPCS,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
SCREW CANC 6.5,3630276,CDM,278,RC,C1713,HCPCS,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
SCREW LAG 65MM,3630285,CDM,278,RC,C1713,HCPCS,Outpatient,,,514.5,308.7,,92.61,18,,,percent of total billed charges,pays at 18% of total charges,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.15,70,,,percent of total billed charges,70% of total billed charges,385.88,75,,,percent of total billed charges,75% of total billed charges,257.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,411.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,514.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,360.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,514.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,514.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.62,514.5,
SCREW LAG,3630289,CDM,278,RC,C1713,HCPCS,Outpatient,,,462,277.2,,83.16,18,,,percent of total billed charges,pays at 18% of total charges,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.4,70,,,percent of total billed charges,70% of total billed charges,346.5,75,,,percent of total billed charges,75% of total billed charges,231,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,369.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,277.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,462,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,462,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.4,462,
SCREW CANN 4.5,3630334,CDM,278,RC,C1713,HCPCS,Outpatient,,,353,211.8,,63.54,18,,,percent of total billed charges,pays at 18% of total charges,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.1,70,,,percent of total billed charges,70% of total billed charges,264.75,75,,,percent of total billed charges,75% of total billed charges,176.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,282.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,247.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,211.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,247.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,353,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.32,353,
SCREW CONICAL,3630343,CDM,278,RC,C1713,HCPCS,Outpatient,,,306.5,183.9,,55.17,18,,,percent of total billed charges,pays at 18% of total charges,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.55,70,,,percent of total billed charges,70% of total billed charges,229.88,75,,,percent of total billed charges,75% of total billed charges,153.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.03,306.5,
SCREW MALLEOLAR,3630351,CDM,278,RC,C1713,HCPCS,Outpatient,,,71.5,42.9,,12.87,18,,,percent of total billed charges,pays at 18% of total charges,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,71.5,
IMPLANT MEDPOR SURGICA,3630356,CDM,278,RC,C1763,HCPCS,Outpatient,,,1748,1048.8,,314.64,18,,,percent of total billed charges,pays at 18% of total charges,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1223.6,70,,,percent of total billed charges,70% of total billed charges,1311,75,,,percent of total billed charges,75% of total billed charges,874,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1048.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1748,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,301.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1223.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1048.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1223.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1748,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1748,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.91,1748,
SCREW CANN 5.0,3630366,CDM,278,RC,C1713,HCPCS,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,333,
SCREW CONNECTING,3630367,CDM,278,RC,C1713,HCPCS,Outpatient,,,276,165.6,,49.68,18,,,percent of total billed charges,pays at 18% of total charges,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.2,70,,,percent of total billed charges,70% of total billed charges,207,75,,,percent of total billed charges,75% of total billed charges,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,276,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,276,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.25,276,
SCREW CANN 4.0,3630373,CDM,278,RC,C1713,HCPCS,Outpatient,,,306.5,183.9,,55.17,18,,,percent of total billed charges,pays at 18% of total charges,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.55,70,,,percent of total billed charges,70% of total billed charges,229.88,75,,,percent of total billed charges,75% of total billed charges,153.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.03,306.5,
SCREW CANN 4.0,3630376,CDM,278,RC,C1713,HCPCS,Outpatient,,,306.5,183.9,,55.17,18,,,percent of total billed charges,pays at 18% of total charges,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.55,70,,,percent of total billed charges,70% of total billed charges,229.88,75,,,percent of total billed charges,75% of total billed charges,153.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.03,306.5,
PLATE 1/4 TUBULAR,3630434,CDM,278,RC,C1713,HCPCS,Outpatient,,,166.5,99.9,,29.97,18,,,percent of total billed charges,pays at 18% of total charges,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.55,70,,,percent of total billed charges,70% of total billed charges,124.88,75,,,percent of total billed charges,75% of total billed charges,83.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,133.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,116.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,166.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.09,166.5,
PLATE T RT ANGLE,3630482,CDM,278,RC,C1713,HCPCS,Outpatient,,,760,456,,136.8,18,,,percent of total billed charges,pays at 18% of total charges,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532,70,,,percent of total billed charges,70% of total billed charges,570,75,,,percent of total billed charges,75% of total billed charges,380,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,760,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,456,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.09,760,
PLATE L LCP TI,3630485,CDM,278,RC,C1713,HCPCS,Outpatient,,,684.5,410.7,,123.21,18,,,percent of total billed charges,pays at 18% of total charges,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.15,70,,,percent of total billed charges,70% of total billed charges,513.38,75,,,percent of total billed charges,75% of total billed charges,342.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,547.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,410.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,684.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,410.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,479.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,684.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,684.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.26,684.5,
FEMORAL COMPONENT,3630498,CDM,278,RC,C1776,HCPCS,Outpatient,,,3946,2367.6,,710.28,18,,,percent of total billed charges,pays at 18% of total charges,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,710.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2762.2,70,,,percent of total billed charges,70% of total billed charges,2959.5,75,,,percent of total billed charges,75% of total billed charges,1973,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2367.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3946,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,679.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1775.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2762.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2367.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1499.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2762.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3946,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3946,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.34,3946,
CLAMP 4.0,3630526,CDM,272,RC,,,Outpatient,,,554.5,332.7,,99.81,18,,,percent of total billed charges,pays at 18% of total charges,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.25,50,,,percent of total billed charges,pays at 50% of total billed charges,388.15,70,,,percent of total billed charges,70% of total billed charges,415.88,75,,,percent of total billed charges,75% of total billed charges,277.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,443.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,424.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,388.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,388.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,554.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,499.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.89,554.5,
PIN STEINMAN PLN,3630538,CDM,278,RC,C1713,HCPCS,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
MAYFIELD SKULL PINS,3630548,CDM,272,RC,,,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
STAPLER PRECISE 35R,3630554,CDM,272,RC,,,Outpatient,,,89.5,53.7,,16.11,18,,,percent of total billed charges,pays at 18% of total charges,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.75,50,,,percent of total billed charges,pays at 50% of total billed charges,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,44.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
STAPLES OSTEOTOMY 5MM,3630558,CDM,272,RC,,,Outpatient,,,316,189.6,,56.88,18,,,percent of total billed charges,pays at 18% of total charges,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158,50,,,percent of total billed charges,pays at 50% of total billed charges,221.2,70,,,percent of total billed charges,70% of total billed charges,237,75,,,percent of total billed charges,75% of total billed charges,158,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,316,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,284.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.52,316,
STAPLES FIXATION MED,3630563,CDM,272,RC,,,Outpatient,,,244.5,146.7,,44.01,18,,,percent of total billed charges,pays at 18% of total charges,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.25,50,,,percent of total billed charges,pays at 50% of total billed charges,171.15,70,,,percent of total billed charges,70% of total billed charges,183.38,75,,,percent of total billed charges,75% of total billed charges,122.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,171.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,171.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,244.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.31,244.5,
ROD CARBON FIBER,3630570,CDM,278,RC,,,Outpatient,,,89.5,53.7,,16.11,18,,,percent of total billed charges,pays at 18% of total charges,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.75,50,,,percent of total billed charges,pays at 50% of total billed charges,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,44.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
ALLOWRAP 2X4 CM PER SQ CM,3630580,CDM,636,RC,Q4150,HCPCS,Outpatient,,,364,218.4,,65.52,18,,,percent of total billed charges,pays at 18% of total charges,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,254.8,70,,,percent of total billed charges,70% of total billed charges,273,75,,,percent of total billed charges,75% of total billed charges,182,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,254.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,254.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,364,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.04,364,
ALLOWRAP 4X4 CM PER SQ CM,3630581,CDM,636,RC,Q4150,HCPCS,Outpatient,,,312,187.2,,56.16,18,,,percent of total billed charges,pays at 18% of total charges,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,218.4,70,,,percent of total billed charges,70% of total billed charges,234,75,,,percent of total billed charges,75% of total billed charges,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,312,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,280.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.89,312,
ALLOWRAP 2X2 CM PER SQ CM,3630582,CDM,636,RC,Q4150,HCPCS,Outpatient,,,416,249.6,,74.88,18,,,percent of total billed charges,pays at 18% of total charges,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,291.2,70,,,percent of total billed charges,70% of total billed charges,312,75,,,percent of total billed charges,75% of total billed charges,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,374.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.19,416,
ALLOWRAP 4X8 CM PER SQ CM,3630583,CDM,636,RC,Q4150,HCPCS,Outpatient,,,176,105.6,,31.68,18,,,percent of total billed charges,pays at 18% of total charges,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges,132,75,,,percent of total billed charges,75% of total billed charges,88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,176,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,158.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.58,176,
ALLOWRAP 2X4 CM PER SQ CM WASTE,3630584,CDM,636,RC,Q4150,HCPCS,Outpatient,,,364,218.4,,65.52,18,,,percent of total billed charges,pays at 18% of total charges,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,254.8,70,,,percent of total billed charges,70% of total billed charges,273,75,,,percent of total billed charges,75% of total billed charges,182,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,291.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,254.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,254.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,364,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.04,364,
ALLOWRAP 4X4 CM PER SQ CM WASTE,3630585,CDM,636,RC,Q4150,HCPCS,Outpatient,,,312,187.2,,56.16,18,,,percent of total billed charges,pays at 18% of total charges,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,218.4,70,,,percent of total billed charges,70% of total billed charges,234,75,,,percent of total billed charges,75% of total billed charges,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,312,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,280.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.89,312,
ALLOWRAP 2X2 CM PER SQ CM WASTE,3630586,CDM,636,RC,Q4150,HCPCS,Outpatient,,,416,249.6,,74.88,18,,,percent of total billed charges,pays at 18% of total charges,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,291.2,70,,,percent of total billed charges,70% of total billed charges,312,75,,,percent of total billed charges,75% of total billed charges,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,374.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.19,416,
ALLOWRAP 4X8 CM PER SQ CM WASTE,3630587,CDM,636,RC,Q4150,HCPCS,Outpatient,,,176,105.6,,31.68,18,,,percent of total billed charges,pays at 18% of total charges,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges,132,75,,,percent of total billed charges,75% of total billed charges,88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,176,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,158.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.58,176,
WASHER THRD,3630649,CDM,278,RC,C1713,HCPCS,Outpatient,,,214,128.4,,38.52,18,,,percent of total billed charges,pays at 18% of total charges,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,214,
WASHER ORTHO,3630651,CDM,278,RC,C1713,HCPCS,Outpatient,,,447.85,268.71,,80.61,18,,,percent of total billed charges,pays at 18% of total charges,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.5,70,,,percent of total billed charges,70% of total billed charges,335.89,75,,,percent of total billed charges,75% of total billed charges,223.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,358.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,447.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,447.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,447.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.18,447.85,
GUIDEWIRE 1.25,3630656,CDM,272,RC,C1769,HCPCS,Outpatient,,,71.5,42.9,,12.87,18,,,percent of total billed charges,pays at 18% of total charges,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.63,75,,,percent of total billed charges,75% of total billed charges,35.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,71.5,
GUIDEWIRE 2.0,3630658,CDM,272,RC,C1769,HCPCS,Outpatient,,,77.5,46.5,,13.95,18,,,percent of total billed charges,pays at 18% of total charges,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.13,75,,,percent of total billed charges,75% of total billed charges,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,77.5,
DRILL BIT 2.7MM,3630664,CDM,272,RC,,,Outpatient,,,559.5,335.7,,100.71,18,,,percent of total billed charges,pays at 18% of total charges,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.75,50,,,percent of total billed charges,pays at 50% of total billed charges,391.65,70,,,percent of total billed charges,70% of total billed charges,419.63,75,,,percent of total billed charges,75% of total billed charges,279.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,447.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,428.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,391.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,335.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,391.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,559.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,503.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.67,559.5,
DRILL BIT 1.5,3630667,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
DRILL BIT 2.0,3630668,CDM,272,RC,,,Outpatient,,,101,60.6,,18.18,18,,,percent of total billed charges,pays at 18% of total charges,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.5,50,,,percent of total billed charges,pays at 50% of total billed charges,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,50.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,101,
DRILL BIT 3.5,3630672,CDM,272,RC,,,Outpatient,,,115.5,69.3,,20.79,18,,,percent of total billed charges,pays at 18% of total charges,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,50,,,percent of total billed charges,pays at 50% of total billed charges,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,57.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,115.5,
K WIRE,3630682,CDM,278,RC,C1713,HCPCS,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
TOOLS DISSECTING AM8,3630689,CDM,272,RC,,,Outpatient,,,312,187.2,,56.16,18,,,percent of total billed charges,pays at 18% of total charges,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156,50,,,percent of total billed charges,pays at 50% of total billed charges,218.4,70,,,percent of total billed charges,70% of total billed charges,234,75,,,percent of total billed charges,75% of total billed charges,156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,249.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,218.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,312,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,280.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.89,312,
TOOL DISSECTING M1,3630704,CDM,272,RC,,,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.5,50,,,percent of total billed charges,pays at 50% of total billed charges,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
TOOLS DISSECTING O2,3630721,CDM,272,RC,,,Outpatient,,,278.5,167.1,,50.13,18,,,percent of total billed charges,pays at 18% of total charges,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.25,50,,,percent of total billed charges,pays at 50% of total billed charges,194.95,70,,,percent of total billed charges,70% of total billed charges,208.88,75,,,percent of total billed charges,75% of total billed charges,139.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,250.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,278.5,
PLATE BROAD 8H,3630732,CDM,278,RC,C1713,HCPCS,Outpatient,,,433.5,260.1,,78.03,18,,,percent of total billed charges,pays at 18% of total charges,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.45,70,,,percent of total billed charges,70% of total billed charges,325.13,75,,,percent of total billed charges,75% of total billed charges,216.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,346.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,433.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,303.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,303.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,433.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,433.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.93,433.5,
CABLE DISPOSAL,3630751,CDM,272,RC,,,Outpatient,,,36.82,22.09,,6.63,18,,,percent of total billed charges,pays at 18% of total charges,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.41,50,,,percent of total billed charges,pays at 50% of total billed charges,25.77,70,,,percent of total billed charges,70% of total billed charges,27.62,75,,,percent of total billed charges,75% of total billed charges,18.41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,25.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.67,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,36.82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,33.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.77,36.82,
SET CABLE NIM DISP,3630752,CDM,272,RC,,,Outpatient,,,360,216,,64.8,18,,,percent of total billed charges,pays at 18% of total charges,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,50,,,percent of total billed charges,pays at 50% of total billed charges,252,70,,,percent of total billed charges,70% of total billed charges,270,75,,,percent of total billed charges,75% of total billed charges,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,360,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,360,
BLADE CARPAL TUNNEL ENDO,3630768,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
PIN TRANSFIXING,3630773,CDM,278,RC,C1713,HCPCS,Outpatient,,,208,124.8,,37.44,18,,,percent of total billed charges,pays at 18% of total charges,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.6,70,,,percent of total billed charges,70% of total billed charges,156,75,,,percent of total billed charges,75% of total billed charges,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,208,
KIT ANKLE INSTRUMENT DISP,3630780,CDM,272,RC,,,Outpatient,,,1248,748.8,,224.64,18,,,percent of total billed charges,pays at 18% of total charges,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,624,50,,,percent of total billed charges,pays at 50% of total billed charges,873.6,70,,,percent of total billed charges,70% of total billed charges,936,75,,,percent of total billed charges,75% of total billed charges,624,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,954.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,474.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1123.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.56,1248,
STRAP ANKLE,3630782,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
CATH IRRIGATION OCCLUSION,3630783,CDM,272,RC,,,Outpatient,,,350,210,,63,18,,,percent of total billed charges,pays at 18% of total charges,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175,50,,,percent of total billed charges,pays at 50% of total billed charges,245,70,,,percent of total billed charges,70% of total billed charges,262.5,75,,,percent of total billed charges,75% of total billed charges,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,350,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,315,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.85,350,
PLATE STRT,3630785,CDM,278,RC,C1713,HCPCS,Outpatient,,,161.5,96.9,,29.07,18,,,percent of total billed charges,pays at 18% of total charges,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.05,70,,,percent of total billed charges,70% of total billed charges,121.13,75,,,percent of total billed charges,75% of total billed charges,80.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,161.5,
BLADE SAW STERNUM,3630788,CDM,272,RC,,,Outpatient,,,65,39,,11.7,18,,,percent of total billed charges,pays at 18% of total charges,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.5,50,,,percent of total billed charges,pays at 50% of total billed charges,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,65,
DRILL BIT,3630792,CDM,272,RC,,,Outpatient,,,379,227.4,,68.22,18,,,percent of total billed charges,pays at 18% of total charges,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.5,50,,,percent of total billed charges,pays at 50% of total billed charges,265.3,70,,,percent of total billed charges,70% of total billed charges,284.25,75,,,percent of total billed charges,75% of total billed charges,189.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,289.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,265.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,265.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,379,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,341.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.39,379,
MINISUCKER,3630798,CDM,272,RC,,,Outpatient,,,75.5,45.3,,13.59,18,,,percent of total billed charges,pays at 18% of total charges,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.75,50,,,percent of total billed charges,pays at 50% of total billed charges,52.85,70,,,percent of total billed charges,70% of total billed charges,56.63,75,,,percent of total billed charges,75% of total billed charges,37.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,75.5,
END CAP,3630799,CDM,278,RC,C1713,HCPCS,Outpatient,,,2300,1380,,414,18,,,percent of total billed charges,pays at 18% of total charges,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,414,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1610,70,,,percent of total billed charges,70% of total billed charges,1725,75,,,percent of total billed charges,75% of total billed charges,1150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1380,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,396.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1035,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1610,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1380,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,874,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1610,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,2300,
CANNULA CLEAR,3630803,CDM,272,RC,,,Outpatient,,,56.5,33.9,,10.17,18,,,percent of total billed charges,pays at 18% of total charges,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.25,50,,,percent of total billed charges,pays at 50% of total billed charges,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,28.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,56.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.85,56.5,
PIN BUTTRESS,3630811,CDM,278,RC,C1713,HCPCS,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
PIN BUTTRESS LCP,3630812,CDM,278,RC,C1713,HCPCS,Outpatient,,,177,106.2,,31.86,18,,,percent of total billed charges,pays at 18% of total charges,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.9,70,,,percent of total billed charges,70% of total billed charges,132.75,75,,,percent of total billed charges,75% of total billed charges,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,123.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,177,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.74,177,
PIN BUTTRESS,3630813,CDM,278,RC,C1713,HCPCS,Outpatient,,,313.65,188.19,,56.46,18,,,percent of total billed charges,pays at 18% of total charges,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.56,70,,,percent of total billed charges,70% of total billed charges,235.24,75,,,percent of total billed charges,75% of total billed charges,156.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,219.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,219.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,313.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,313.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.15,313.65,
NAIL ELASTIC,3630814,CDM,278,RC,C1713,HCPCS,Outpatient,,,664.12,398.47,,119.54,18,,,percent of total billed charges,pays at 18% of total charges,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.88,70,,,percent of total billed charges,70% of total billed charges,498.09,75,,,percent of total billed charges,75% of total billed charges,332.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,531.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,398.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,664.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,464.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,464.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,664.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,664.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.07,664.12,
PIN DOCKING,3630815,CDM,272,RC,,,Outpatient,,,687.7,412.62,,123.79,18,,,percent of total billed charges,pays at 18% of total charges,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.85,50,,,percent of total billed charges,pays at 50% of total billed charges,481.39,70,,,percent of total billed charges,70% of total billed charges,515.78,75,,,percent of total billed charges,75% of total billed charges,343.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,550.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,412.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,526.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,481.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,481.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,687.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,618.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,687.7,
PLATE,3630825,CDM,278,RC,C1713,HCPCS,Outpatient,,,1982.5,1189.5,,356.85,18,,,percent of total billed charges,pays at 18% of total charges,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.75,70,,,percent of total billed charges,70% of total billed charges,1486.88,75,,,percent of total billed charges,75% of total billed charges,991.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1586,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1189.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1982.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1387.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1189.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,753.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1387.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1982.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1982.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,310.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.66,1982.5,
SCREW CORT TI,3630826,CDM,278,RC,C1713,HCPCS,Outpatient,,,139.5,83.7,,25.11,18,,,percent of total billed charges,pays at 18% of total charges,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.65,70,,,percent of total billed charges,70% of total billed charges,104.63,75,,,percent of total billed charges,75% of total billed charges,69.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,97.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,139.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,139.5,
SCREW HEADLESS,3630827,CDM,278,RC,C1713,HCPCS,Outpatient,,,347,208.2,,62.46,18,,,percent of total billed charges,pays at 18% of total charges,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.9,70,,,percent of total billed charges,70% of total billed charges,260.25,75,,,percent of total billed charges,75% of total billed charges,173.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,242.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,242.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,347,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,347,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.37,347,
ELECTRODE VAPR SIDE EFFEC,3630833,CDM,272,RC,,,Outpatient,,,452.5,271.5,,81.45,18,,,percent of total billed charges,pays at 18% of total charges,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.25,50,,,percent of total billed charges,pays at 50% of total billed charges,316.75,70,,,percent of total billed charges,70% of total billed charges,339.38,75,,,percent of total billed charges,75% of total billed charges,226.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,362,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,452.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,452.5,
KIT PREP ORTHO,3630849,CDM,272,RC,,,Outpatient,,,478.5,287.1,,86.13,18,,,percent of total billed charges,pays at 18% of total charges,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.25,50,,,percent of total billed charges,pays at 50% of total billed charges,334.95,70,,,percent of total billed charges,70% of total billed charges,358.88,75,,,percent of total billed charges,75% of total billed charges,239.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,366.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,334.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,334.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,478.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,430.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.98,478.5,
OSTEOTOME,3630862,CDM,272,RC,,,Outpatient,,,547,328.2,,98.46,18,,,percent of total billed charges,pays at 18% of total charges,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,273.5,50,,,percent of total billed charges,pays at 50% of total billed charges,382.9,70,,,percent of total billed charges,70% of total billed charges,410.25,75,,,percent of total billed charges,75% of total billed charges,273.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,437.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,382.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,328.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,382.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,547,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,492.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.71,547,
SCREW CANN LCKG,3630864,CDM,278,RC,C1713,HCPCS,Outpatient,,,395.5,237.3,,71.19,18,,,percent of total billed charges,pays at 18% of total charges,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.85,70,,,percent of total billed charges,70% of total billed charges,296.63,75,,,percent of total billed charges,75% of total billed charges,197.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,316.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,276.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,237.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,276.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,395.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,395.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.97,395.5,
HOOK CEMENT,3630865,CDM,278,RC,C1713,HCPCS,Outpatient,,,713,427.8,,128.34,18,,,percent of total billed charges,pays at 18% of total charges,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.1,70,,,percent of total billed charges,70% of total billed charges,534.75,75,,,percent of total billed charges,75% of total billed charges,356.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,570.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,713,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,499.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,713,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,713,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.73,713,
WIRE CERCLAGE COILS,3630876,CDM,278,RC,C1713,HCPCS,Outpatient,,,106,63.6,,19.08,18,,,percent of total billed charges,pays at 18% of total charges,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,106,
HOOKS DISSECTING,3630881,CDM,272,RC,,,Outpatient,,,269,161.4,,48.42,18,,,percent of total billed charges,pays at 18% of total charges,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.5,50,,,percent of total billed charges,pays at 50% of total billed charges,188.3,70,,,percent of total billed charges,70% of total billed charges,201.75,75,,,percent of total billed charges,75% of total billed charges,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,242.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.15,269,
FEMORAL HEAD,3630912,CDM,278,RC,C1776,HCPCS,Outpatient,,,1658,994.8,,298.44,18,,,percent of total billed charges,pays at 18% of total charges,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1160.6,70,,,percent of total billed charges,70% of total billed charges,1243.5,75,,,percent of total billed charges,75% of total billed charges,829,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,994.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1658,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,285.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1160.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,994.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1160.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1658,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1658,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.81,1658,
PATELLA BUTTON,3630922,CDM,278,RC,C1776,HCPCS,Outpatient,,,1551,930.6,,279.18,18,,,percent of total billed charges,pays at 18% of total charges,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1085.7,70,,,percent of total billed charges,70% of total billed charges,1163.25,75,,,percent of total billed charges,75% of total billed charges,775.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1240.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,930.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1551,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,267.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1085.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,930.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1085.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1551,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1551,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.04,1551,
END CAP PROTECTIVE,3630935,CDM,272,RC,,,Outpatient,,,89.1,53.46,,16.04,18,,,percent of total billed charges,pays at 18% of total charges,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.55,50,,,percent of total billed charges,pays at 50% of total billed charges,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,44.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.96,89.1,
PACK TOTAL KNEE,3630968,CDM,272,RC,,,Outpatient,,,373,223.8,,67.14,18,,,percent of total billed charges,pays at 18% of total charges,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.5,50,,,percent of total billed charges,pays at 50% of total billed charges,261.1,70,,,percent of total billed charges,70% of total billed charges,279.75,75,,,percent of total billed charges,75% of total billed charges,186.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,298.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,261.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,223.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,261.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,373,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,335.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.45,373,
PACK PUMP,3630970,CDM,272,RC,,,Outpatient,,,1531,918.6,,275.58,18,,,percent of total billed charges,pays at 18% of total charges,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1071.7,70,,,percent of total billed charges,70% of total billed charges,1148.25,75,,,percent of total billed charges,75% of total billed charges,765.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1171.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1071.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,918.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,581.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1071.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1531,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1377.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.91,1531,
SCREW INTERFERENCE,3630975,CDM,278,RC,C1713,HCPCS,Outpatient,,,487,292.2,,87.66,18,,,percent of total billed charges,pays at 18% of total charges,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.9,70,,,percent of total billed charges,70% of total billed charges,365.25,75,,,percent of total billed charges,75% of total billed charges,243.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,389.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,340.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,340.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,487,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,487,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,487,
PIN CASPER DISTRACTION,3630978,CDM,272,RC,,,Outpatient,,,377,226.2,,67.86,18,,,percent of total billed charges,pays at 18% of total charges,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.5,50,,,percent of total billed charges,pays at 50% of total billed charges,263.9,70,,,percent of total billed charges,70% of total billed charges,282.75,75,,,percent of total billed charges,75% of total billed charges,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,301.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,226.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,263.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,377,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,339.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.08,377,
NAIL EXTRACTOR DISP,3630980,CDM,272,RC,,,Outpatient,,,577.75,346.65,,104,18,,,percent of total billed charges,pays at 18% of total charges,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.88,50,,,percent of total billed charges,pays at 50% of total billed charges,404.43,70,,,percent of total billed charges,70% of total billed charges,433.31,75,,,percent of total billed charges,75% of total billed charges,288.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,462.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,346.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,404.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,346.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,404.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,577.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,519.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.53,577.75,
ACETABULAR LINER,3630986,CDM,278,RC,C1776,HCPCS,Outpatient,,,2348,1408.8,,422.64,18,,,percent of total billed charges,pays at 18% of total charges,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,422.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.6,70,,,percent of total billed charges,70% of total billed charges,1761,75,,,percent of total billed charges,75% of total billed charges,1174,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1878.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1408.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2348,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,404.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1056.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1643.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1643.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2348,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2348,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.93,2348,
PACK OPEN HEART #1,3630998,CDM,272,RC,,,Outpatient,,,887,532.2,,159.66,18,,,percent of total billed charges,pays at 18% of total charges,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.5,50,,,percent of total billed charges,pays at 50% of total billed charges,620.9,70,,,percent of total billed charges,70% of total billed charges,665.25,75,,,percent of total billed charges,75% of total billed charges,443.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,532.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,678.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,620.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,532.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,620.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,887,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,798.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.99,887,
FEMORAL COMPONENT,3631030,CDM,278,RC,C1776,HCPCS,Outpatient,,,3641.5,2184.9,,655.47,18,,,percent of total billed charges,pays at 18% of total charges,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2549.05,70,,,percent of total billed charges,70% of total billed charges,2731.13,75,,,percent of total billed charges,75% of total billed charges,1820.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2913.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2184.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3641.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,627.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2549.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2184.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1383.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2549.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1747.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3641.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3641.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,570.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.62,3641.5,
TIBIAL INSERT,3631032,CDM,278,RC,C1776,HCPCS,Outpatient,,,1447,868.2,,260.46,18,,,percent of total billed charges,pays at 18% of total charges,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.9,70,,,percent of total billed charges,70% of total billed charges,1085.25,75,,,percent of total billed charges,75% of total billed charges,723.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,868.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1447,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,249.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1012.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,868.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1012.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.74,1447,
PATELLA OVAL DOME,3631033,CDM,278,RC,C1776,HCPCS,Outpatient,,,824.5,494.7,,148.41,18,,,percent of total billed charges,pays at 18% of total charges,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.15,70,,,percent of total billed charges,70% of total billed charges,618.38,75,,,percent of total billed charges,75% of total billed charges,412.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,659.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,494.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,824.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,494.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,577.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,824.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,824.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.2,824.5,
DRILL BIT 4.0,3631053,CDM,272,RC,,,Outpatient,,,164,98.4,,29.52,18,,,percent of total billed charges,pays at 18% of total charges,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,164,
SCREW SCHANZ,3631065,CDM,278,RC,C1713,HCPCS,Outpatient,,,286.5,171.9,,51.57,18,,,percent of total billed charges,pays at 18% of total charges,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.55,70,,,percent of total billed charges,70% of total billed charges,214.88,75,,,percent of total billed charges,75% of total billed charges,143.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,229.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,200.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,286.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,286.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.89,286.5,
PLATE DIST RADIUS SM,3631070,CDM,278,RC,C1713,HCPCS,Outpatient,,,726.5,435.9,,130.77,18,,,percent of total billed charges,pays at 18% of total charges,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.55,70,,,percent of total billed charges,70% of total billed charges,544.88,75,,,percent of total billed charges,75% of total billed charges,363.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,581.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,435.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,726.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,125.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,508.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,435.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,508.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,726.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,726.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.84,726.5,
SCREW CORT TI,3631077,CDM,278,RC,C1713,HCPCS,Outpatient,,,111,66.6,,19.98,18,,,percent of total billed charges,pays at 18% of total charges,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.7,70,,,percent of total billed charges,70% of total billed charges,83.25,75,,,percent of total billed charges,75% of total billed charges,55.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.39,111,
CATH COUDE,3631087,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
CATH COUDE,3631089,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
CATH URETHRAL,3631110,CDM,272,RC,C1758,HCPCS,Outpatient,,,23,13.8,,4.14,18,,,percent of total billed charges,pays at 18% of total charges,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,70,,,percent of total billed charges,70% of total billed charges,17.25,75,,,percent of total billed charges,75% of total billed charges,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,23,
CATH ROB NEL,3631112,CDM,272,RC,,,Outpatient,,,2,1.2,,0.36,18,,,percent of total billed charges,pays at 18% of total charges,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1,50,,,percent of total billed charges,pays at 50% of total billed charges,1.4,70,,,percent of total billed charges,70% of total billed charges,1.5,75,,,percent of total billed charges,75% of total billed charges,1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.31,2,
DRIVER DISP,3631121,CDM,272,RC,,,Outpatient,,,789.1,473.46,,142.04,18,,,percent of total billed charges,pays at 18% of total charges,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.55,50,,,percent of total billed charges,pays at 50% of total billed charges,552.37,70,,,percent of total billed charges,70% of total billed charges,591.83,75,,,percent of total billed charges,75% of total billed charges,394.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,631.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,473.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,603.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,552.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,473.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,552.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,789.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,710.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.65,789.1,
SHAVER ORTHO,3631122,CDM,272,RC,,,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390,50,,,percent of total billed charges,pays at 50% of total billed charges,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,702,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
TUBING PUMP ORTHO,3631123,CDM,272,RC,,,Outpatient,,,142.5,85.5,,25.65,18,,,percent of total billed charges,pays at 18% of total charges,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.25,50,,,percent of total billed charges,pays at 50% of total billed charges,99.75,70,,,percent of total billed charges,70% of total billed charges,106.88,75,,,percent of total billed charges,75% of total billed charges,71.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,99.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,128.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.33,142.5,
CATH TROCAR,3631140,CDM,272,RC,C1729,HCPCS,Outpatient,,,59,35.4,,10.62,18,,,percent of total billed charges,pays at 18% of total charges,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.3,70,,,percent of total billed charges,70% of total billed charges,44.25,75,,,percent of total billed charges,75% of total billed charges,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,59,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,59,
CATTEL T TUBE,3631147,CDM,272,RC,,,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21,50,,,percent of total billed charges,pays at 50% of total billed charges,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
ADAPTER SWIVEL PORTEX,3631171,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
BAG BILE,3631178,CDM,272,RC,,,Outpatient,,,31.5,18.9,,5.67,18,,,percent of total billed charges,pays at 18% of total charges,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,50,,,percent of total billed charges,pays at 50% of total billed charges,22.05,70,,,percent of total billed charges,70% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,15.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,31.5,
SYS CHEST DRAIN,3631196,CDM,272,RC,,,Outpatient,,,363.5,218.1,,65.43,18,,,percent of total billed charges,pays at 18% of total charges,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.75,50,,,percent of total billed charges,pays at 50% of total billed charges,254.45,70,,,percent of total billed charges,70% of total billed charges,272.63,75,,,percent of total billed charges,75% of total billed charges,181.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,290.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,254.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,254.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,363.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.96,363.5,
TIBIAL PLATE,3631208,CDM,278,RC,C1776,HCPCS,Outpatient,,,2809,1685.4,,505.62,18,,,percent of total billed charges,pays at 18% of total charges,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,505.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1966.3,70,,,percent of total billed charges,70% of total billed charges,2106.75,75,,,percent of total billed charges,75% of total billed charges,1404.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1685.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2809,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,483.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1264.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1966.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1685.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1067.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1966.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1348.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2809,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2809,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.17,2809,
ORGIN TACKER SYS,3631240,CDM,278,RC,C1713,HCPCS,Outpatient,,,699.5,419.7,,125.91,18,,,percent of total billed charges,pays at 18% of total charges,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.65,70,,,percent of total billed charges,70% of total billed charges,524.63,75,,,percent of total billed charges,75% of total billed charges,349.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,559.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,419.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,699.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,489.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,419.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,489.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,699.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,699.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.61,699.5,
KNIFE ARACHNOID,3631245,CDM,272,RC,,,Outpatient,,,103,61.8,,18.54,18,,,percent of total billed charges,pays at 18% of total charges,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.5,50,,,percent of total billed charges,pays at 50% of total billed charges,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,103,
END CAP,3631260,CDM,278,RC,C1713,HCPCS,Outpatient,,,665,399,,119.7,18,,,percent of total billed charges,pays at 18% of total charges,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.5,70,,,percent of total billed charges,70% of total billed charges,498.75,75,,,percent of total billed charges,75% of total billed charges,332.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,532,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,399,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,665,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,465.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,399,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,465.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,665,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,665,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.21,665,
KIT MENISCECTOMY ELECTROD,3631267,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
KIT PERCT INTRO 8.5 FR,3631276,CDM,272,RC,,,Outpatient,,,135.5,81.3,,24.39,18,,,percent of total billed charges,pays at 18% of total charges,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.75,50,,,percent of total billed charges,pays at 50% of total billed charges,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,67.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,135.5,
WIRE STERNAL,3631277,CDM,272,RC,,,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44,50,,,percent of total billed charges,pays at 50% of total billed charges,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
WIRE SUTURE DOUBLE STERNAL,3631278,CDM,272,RC,,,Outpatient,,,182,109.2,,32.76,18,,,percent of total billed charges,pays at 18% of total charges,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91,50,,,percent of total billed charges,pays at 50% of total billed charges,127.4,70,,,percent of total billed charges,70% of total billed charges,136.5,75,,,percent of total billed charges,75% of total billed charges,91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,182,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.52,182,
CLIP ANEURYSM,3631301,CDM,272,RC,,,Outpatient,,,793,475.8,,142.74,18,,,percent of total billed charges,pays at 18% of total charges,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,396.5,50,,,percent of total billed charges,pays at 50% of total billed charges,555.1,70,,,percent of total billed charges,70% of total billed charges,594.75,75,,,percent of total billed charges,75% of total billed charges,396.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,475.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,606.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,555.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,475.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,555.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,793,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,713.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.26,793,
STOPCOCK 3 WAY,3631330,CDM,272,RC,,,Outpatient,,,5.5,3.3,,0.99,18,,,percent of total billed charges,pays at 18% of total charges,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.75,50,,,percent of total billed charges,pays at 50% of total billed charges,3.85,70,,,percent of total billed charges,70% of total billed charges,4.13,75,,,percent of total billed charges,75% of total billed charges,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,5.5,
STYLET STRAIGHTENING,3631331,CDM,272,RC,,,Outpatient,,,175.55,105.33,,31.6,18,,,percent of total billed charges,pays at 18% of total charges,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.78,50,,,percent of total billed charges,pays at 50% of total billed charges,122.89,70,,,percent of total billed charges,70% of total billed charges,131.66,75,,,percent of total billed charges,75% of total billed charges,87.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,158,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.51,175.55,
SUCTION SIGMOIDOSCOPIC,3631334,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
IMPLANT SPINE INTERBODY 11X20,3631345,CDM,278,RC,,,Outpatient,,,4928.5,2957.1,,887.13,18,,,percent of total billed charges,pays at 18% of total charges,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2464.25,50,,,percent of total billed charges,pays at 50% of total billed charges,3449.95,70,,,percent of total billed charges,70% of total billed charges,3696.38,75,,,percent of total billed charges,75% of total billed charges,2464.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3942.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2957.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4928.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2217.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3449.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2957.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1872.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3449.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2365.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4928.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4928.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.3,4928.5,
TRACH TUBE BIVONA,3631346,CDM,272,RC,,,Outpatient,,,189,113.4,,34.02,18,,,percent of total billed charges,pays at 18% of total charges,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,50,,,percent of total billed charges,pays at 50% of total billed charges,132.3,70,,,percent of total billed charges,70% of total billed charges,141.75,75,,,percent of total billed charges,75% of total billed charges,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,189,
TRAP MUCOUS,3631348,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
FINGER TRAP,3631350,CDM,272,RC,,,Outpatient,,,202,121.2,,36.36,18,,,percent of total billed charges,pays at 18% of total charges,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101,50,,,percent of total billed charges,pays at 50% of total billed charges,141.4,70,,,percent of total billed charges,70% of total billed charges,151.5,75,,,percent of total billed charges,75% of total billed charges,101,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,202,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.65,202,
HUMERAL HEAD,3631353,CDM,278,RC,C1776,HCPCS,Outpatient,,,4820,2892,,867.6,18,,,percent of total billed charges,pays at 18% of total charges,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,867.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3374,70,,,percent of total billed charges,70% of total billed charges,3615,75,,,percent of total billed charges,75% of total billed charges,2410,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3856,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2892,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4820,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,830.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2169,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3374,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2892,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1831.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3374,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2313.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4820,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4820,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.29,4820,
HUMERAL HEAD,3631355,CDM,278,RC,C1776,HCPCS,Outpatient,,,2582,1549.2,,464.76,18,,,percent of total billed charges,pays at 18% of total charges,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,464.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1807.4,70,,,percent of total billed charges,70% of total billed charges,1936.5,75,,,percent of total billed charges,75% of total billed charges,1291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2065.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1549.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2582,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,444.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1807.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1549.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,981.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1807.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2582,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2582,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.6,2582,
BARRIER ADHESION,3631357,CDM,272,RC,C1765,HCPCS,Outpatient,,,439,263.4,,79.02,18,,,percent of total billed charges,pays at 18% of total charges,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.3,70,,,percent of total billed charges,70% of total billed charges,329.25,75,,,percent of total billed charges,75% of total billed charges,219.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,351.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,263.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,335.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,307.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,263.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,307.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,395.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.79,439,
ANESTHESIA CIRCUIT PEDI,3631358,CDM,370,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
ANESTHESIA CIRCUIT ADULT,3631359,CDM,370,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
SCREW SIZER,3631360,CDM,272,RC,,,Outpatient,,,84,50.4,,15.12,18,,,percent of total billed charges,pays at 18% of total charges,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,50,,,percent of total billed charges,pays at 50% of total billed charges,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,75.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,84,
SCREW BONE,3631369,CDM,278,RC,C1713,HCPCS,Outpatient,,,280.5,168.3,,50.49,18,,,percent of total billed charges,pays at 18% of total charges,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.35,70,,,percent of total billed charges,70% of total billed charges,210.38,75,,,percent of total billed charges,75% of total billed charges,140.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,280.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.95,280.5,
SET AMPLATZ RENAL DILATAT,3631393,CDM,272,RC,,,Outpatient,,,472.5,283.5,,85.05,18,,,percent of total billed charges,pays at 18% of total charges,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.25,50,,,percent of total billed charges,pays at 50% of total billed charges,330.75,70,,,percent of total billed charges,70% of total billed charges,354.38,75,,,percent of total billed charges,75% of total billed charges,236.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,378,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,330.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,330.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,472.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,425.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.04,472.5,
KIT GASTRO TUBE,3631406,CDM,272,RC,,,Outpatient,,,175,105,,31.5,18,,,percent of total billed charges,pays at 18% of total charges,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.5,50,,,percent of total billed charges,pays at 50% of total billed charges,122.5,70,,,percent of total billed charges,70% of total billed charges,131.25,75,,,percent of total billed charges,75% of total billed charges,87.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,175,
KIT CATH DBL LUMEN,3631431,CDM,272,RC,C1751,HCPCS,Outpatient,,,280,168,,50.4,18,,,percent of total billed charges,pays at 18% of total charges,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,280,
TUBE VENT PE,3631439,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
SEALANT FIBRIN 2ML,3631445,CDM,272,RC,,,Outpatient,,,181,108.6,,32.58,18,,,percent of total billed charges,pays at 18% of total charges,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.5,50,,,percent of total billed charges,pays at 50% of total billed charges,126.7,70,,,percent of total billed charges,70% of total billed charges,135.75,75,,,percent of total billed charges,75% of total billed charges,90.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,126.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,162.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.36,181,
SET RADIAL ARTERY CATH,3631457,CDM,272,RC,,,Outpatient,,,35.5,21.3,,6.39,18,,,percent of total billed charges,pays at 18% of total charges,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.75,50,,,percent of total billed charges,pays at 50% of total billed charges,24.85,70,,,percent of total billed charges,70% of total billed charges,26.63,75,,,percent of total billed charges,75% of total billed charges,17.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.56,35.5,
BINDER ABDOMINAL,3631458,CDM,272,RC,,,Outpatient,,,87,52.2,,15.66,18,,,percent of total billed charges,pays at 18% of total charges,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,43.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.63,87,
SPLINT CUS LGTH FIBERGL 3 IN,3631463,CDM,272,RC,,,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
SPLINT CUST LGHT FIBERG 5 IN,3631464,CDM,272,RC,,,Outpatient,,,10.5,6.3,,1.89,18,,,percent of total billed charges,pays at 18% of total charges,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.25,50,,,percent of total billed charges,pays at 50% of total billed charges,7.35,70,,,percent of total billed charges,70% of total billed charges,7.88,75,,,percent of total billed charges,75% of total billed charges,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,10.5,
FEMORAL COMPONENT,3631478,CDM,278,RC,C1776,HCPCS,Outpatient,,,3419,2051.4,,615.42,18,,,percent of total billed charges,pays at 18% of total charges,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,615.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2393.3,70,,,percent of total billed charges,70% of total billed charges,2564.25,75,,,percent of total billed charges,75% of total billed charges,1709.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2735.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2051.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3419,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,589.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1538.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2393.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2051.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1299.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2393.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1641.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3419,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3419,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,535.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.76,3419,
SPLINT FINGER,3631490,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
ADHESIVE DERMABOND,3631491,CDM,272,RC,,,Outpatient,,,149,89.4,,26.82,18,,,percent of total billed charges,pays at 18% of total charges,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.5,50,,,percent of total billed charges,pays at 50% of total billed charges,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,149,
DSG PREVENA PEEL & STICK,3631495,CDM,272,RC,,,Outpatient,,,643.5,386.1,,115.83,18,,,percent of total billed charges,pays at 18% of total charges,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.75,50,,,percent of total billed charges,pays at 50% of total billed charges,450.45,70,,,percent of total billed charges,70% of total billed charges,482.63,75,,,percent of total billed charges,75% of total billed charges,321.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,492.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,579.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,643.5,
DSG PREVENA,3631496,CDM,272,RC,,,Outpatient,,,383.5,230.1,,69.03,18,,,percent of total billed charges,pays at 18% of total charges,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.75,50,,,percent of total billed charges,pays at 50% of total billed charges,268.45,70,,,percent of total billed charges,70% of total billed charges,287.63,75,,,percent of total billed charges,75% of total billed charges,191.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,306.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,293.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,268.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,268.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,383.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,345.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.09,383.5,
TUBE SHILEY,3631505,CDM,272,RC,,,Outpatient,,,124,74.4,,22.32,18,,,percent of total billed charges,pays at 18% of total charges,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62,50,,,percent of total billed charges,pays at 50% of total billed charges,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,124,
GLIDEWIRE .035,3631532,CDM,272,RC,C1769,HCPCS,Outpatient,,,119.5,71.7,,21.51,18,,,percent of total billed charges,pays at 18% of total charges,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.63,75,,,percent of total billed charges,75% of total billed charges,59.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,83.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,119.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.73,119.5,
TOOL DISSECTING B-1,3631537,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
PACK CONSTELLATION TOTAL PLUS,3631551,CDM,272,RC,,,Outpatient,,,765.7,459.42,,137.83,18,,,percent of total billed charges,pays at 18% of total charges,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382.85,50,,,percent of total billed charges,pays at 50% of total billed charges,535.99,70,,,percent of total billed charges,70% of total billed charges,574.28,75,,,percent of total billed charges,75% of total billed charges,382.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,585.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,535.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,535.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,765.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,689.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.99,765.7,
PROBE FOGARTY BILIARY,3631556,CDM,272,RC,,,Outpatient,,,143,85.8,,25.74,18,,,percent of total billed charges,pays at 18% of total charges,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.5,50,,,percent of total billed charges,pays at 50% of total billed charges,100.1,70,,,percent of total billed charges,70% of total billed charges,107.25,75,,,percent of total billed charges,75% of total billed charges,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,143,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,128.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,143,
TOOL DISSECTING M-8,3631558,CDM,272,RC,,,Outpatient,,,280.5,168.3,,50.49,18,,,percent of total billed charges,pays at 18% of total charges,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.25,50,,,percent of total billed charges,pays at 50% of total billed charges,196.35,70,,,percent of total billed charges,70% of total billed charges,210.38,75,,,percent of total billed charges,75% of total billed charges,140.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.95,280.5,
TOOL DISSECTING M-3,3631559,CDM,272,RC,,,Outpatient,,,219.5,131.7,,39.51,18,,,percent of total billed charges,pays at 18% of total charges,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.75,50,,,percent of total billed charges,pays at 50% of total billed charges,153.65,70,,,percent of total billed charges,70% of total billed charges,164.63,75,,,percent of total billed charges,75% of total billed charges,109.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,219.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,197.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.4,219.5,
ROD CARBON 200MM,3631621,CDM,278,RC,,,Outpatient,,,412.5,247.5,,74.25,18,,,percent of total billed charges,pays at 18% of total charges,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.25,50,,,percent of total billed charges,pays at 50% of total billed charges,288.75,70,,,percent of total billed charges,70% of total billed charges,309.38,75,,,percent of total billed charges,75% of total billed charges,206.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,288.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,288.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,412.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,412.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.64,412.5,
TIBIAL INSERT WEDGE,3631622,CDM,278,RC,C1713,HCPCS,Outpatient,,,1508,904.8,,271.44,18,,,percent of total billed charges,pays at 18% of total charges,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,271.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1055.6,70,,,percent of total billed charges,70% of total billed charges,1131,75,,,percent of total billed charges,75% of total billed charges,754,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,904.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1508,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,259.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1055.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,904.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,573.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1055.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1508,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1508,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.3,1508,
BONE CANC,3631630,CDM,278,RC,,,Outpatient,,,942.5,565.5,,169.65,18,,,percent of total billed charges,pays at 18% of total charges,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,471.25,50,,,percent of total billed charges,pays at 50% of total billed charges,659.75,70,,,percent of total billed charges,70% of total billed charges,706.88,75,,,percent of total billed charges,75% of total billed charges,471.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,754,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,565.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,942.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,659.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,565.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,659.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,942.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,942.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.69,942.5,
BONE CANC,3631631,CDM,278,RC,,,Outpatient,,,2398.5,1439.1,,431.73,18,,,percent of total billed charges,pays at 18% of total charges,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,431.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1199.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1678.95,70,,,percent of total billed charges,70% of total billed charges,1798.88,75,,,percent of total billed charges,75% of total billed charges,1199.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1918.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1439.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2398.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1678.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1439.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,911.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1678.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1151.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2398.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2398.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.84,2398.5,
VALVULOTOME LEMAITRE,3631632,CDM,272,RC,,,Outpatient,,,926,555.6,,166.68,18,,,percent of total billed charges,pays at 18% of total charges,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463,50,,,percent of total billed charges,pays at 50% of total billed charges,648.2,70,,,percent of total billed charges,70% of total billed charges,694.5,75,,,percent of total billed charges,75% of total billed charges,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,708.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,648.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,555.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,648.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,926,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,833.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.1,926,
BONE CANC,3631634,CDM,278,RC,,,Outpatient,,,1345,807,,242.1,18,,,percent of total billed charges,pays at 18% of total charges,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,672.5,50,,,percent of total billed charges,pays at 50% of total billed charges,941.5,70,,,percent of total billed charges,70% of total billed charges,1008.75,75,,,percent of total billed charges,75% of total billed charges,672.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1076,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,807,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1345,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,941.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,807,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,511.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,941.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1345,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1345,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.76,1345,
VALVULOTOME LEMAITRE HYDRO,3631635,CDM,272,RC,,,Outpatient,,,2572.7,1543.62,,463.09,18,,,percent of total billed charges,pays at 18% of total charges,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1286.35,50,,,percent of total billed charges,pays at 50% of total billed charges,1800.89,70,,,percent of total billed charges,70% of total billed charges,1929.53,75,,,percent of total billed charges,75% of total billed charges,1286.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2058.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1543.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1968.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1157.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1800.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1543.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,977.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1800.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1234.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2572.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2315.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,403.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.14,2572.7,
SET INTRODUCER PEEL-AWAY,3631636,CDM,272,RC,,,Outpatient,,,161.5,96.9,,29.07,18,,,percent of total billed charges,pays at 18% of total charges,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.75,50,,,percent of total billed charges,pays at 50% of total billed charges,113.05,70,,,percent of total billed charges,70% of total billed charges,121.13,75,,,percent of total billed charges,75% of total billed charges,80.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,161.5,
RELOAD ENDO LINEAR THORACIC,3631639,CDM,272,RC,,,Outpatient,,,418,250.8,,75.24,18,,,percent of total billed charges,pays at 18% of total charges,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209,50,,,percent of total billed charges,pays at 50% of total billed charges,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,209,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,376.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,418,
ROD CONNECTOR/CLAMP,3631640,CDM,278,RC,,,Outpatient,,,6825,4095,,1228.5,18,,,percent of total billed charges,pays at 18% of total charges,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3412.5,50,,,percent of total billed charges,pays at 50% of total billed charges,4777.5,70,,,percent of total billed charges,70% of total billed charges,5118.75,75,,,percent of total billed charges,75% of total billed charges,3412.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4095,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6825,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3071.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4777.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4095,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2593.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4777.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3276,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1069.48,6825,
VALVULOTOME LEMAITRE HYDRO,3631642,CDM,272,RC,,,Outpatient,,,3313.7,1988.22,,596.47,18,,,percent of total billed charges,pays at 18% of total charges,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1656.85,50,,,percent of total billed charges,pays at 50% of total billed charges,2319.59,70,,,percent of total billed charges,70% of total billed charges,2485.28,75,,,percent of total billed charges,75% of total billed charges,1656.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2650.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1988.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2534.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1491.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2319.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1988.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1259.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2319.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1590.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3313.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2982.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.26,3313.7,
STAPLER MULTFIRE,3631648,CDM,272,RC,,,Outpatient,,,412.5,247.5,,74.25,18,,,percent of total billed charges,pays at 18% of total charges,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.25,50,,,percent of total billed charges,pays at 50% of total billed charges,288.75,70,,,percent of total billed charges,70% of total billed charges,309.38,75,,,percent of total billed charges,75% of total billed charges,206.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,288.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,288.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,412.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,371.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.64,412.5,
PLATE 40MM,3631649,CDM,278,RC,C1713,HCPCS,Outpatient,,,1610.5,966.3,,289.89,18,,,percent of total billed charges,pays at 18% of total charges,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,289.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.35,70,,,percent of total billed charges,70% of total billed charges,1207.88,75,,,percent of total billed charges,75% of total billed charges,805.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1288.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,966.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1610.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,277.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1127.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,966.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,611.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1127.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1610.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1610.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.37,1610.5,
MEROCEL SINUSTENT DRSG,3631665,CDM,272,RC,,,Outpatient,,,63,37.8,,11.34,18,,,percent of total billed charges,pays at 18% of total charges,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,50,,,percent of total billed charges,pays at 50% of total billed charges,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,63,
BANDAGE ACE XLONG,3631673,CDM,272,RC,,,Outpatient,,,31.5,18.9,,5.67,18,,,percent of total billed charges,pays at 18% of total charges,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,50,,,percent of total billed charges,pays at 50% of total billed charges,22.05,70,,,percent of total billed charges,70% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,15.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,31.5,
CATH VENTRICULAR,3631687,CDM,272,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
BLADE INCISOR,3631693,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
TOOL DISSECTING,3631703,CDM,272,RC,,,Outpatient,,,213,127.8,,38.34,18,,,percent of total billed charges,pays at 18% of total charges,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.5,50,,,percent of total billed charges,pays at 50% of total billed charges,149.1,70,,,percent of total billed charges,70% of total billed charges,159.75,75,,,percent of total billed charges,75% of total billed charges,106.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,170.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,149.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,213,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,191.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.38,213,
BLADE RAZOR CUT,3631714,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
BLADE STONE CUTTER,3631715,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
PLATE RECON LCP,3631758,CDM,278,RC,C1713,HCPCS,Outpatient,,,852,511.2,,153.36,18,,,percent of total billed charges,pays at 18% of total charges,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.4,70,,,percent of total billed charges,70% of total billed charges,639,75,,,percent of total billed charges,75% of total billed charges,426,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,681.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,511.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,596.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,511.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,596.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,852,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,852,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.51,852,
PLATE LCP 9H TO 12H,3631759,CDM,278,RC,C1713,HCPCS,Outpatient,,,557,334.2,,100.26,18,,,percent of total billed charges,pays at 18% of total charges,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.9,70,,,percent of total billed charges,70% of total billed charges,417.75,75,,,percent of total billed charges,75% of total billed charges,278.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,557,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,389.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,389.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,557,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,557,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.28,557,
SCREW LCKG 6.0,3631799,CDM,278,RC,C1713,HCPCS,Outpatient,,,301.5,180.9,,54.27,18,,,percent of total billed charges,pays at 18% of total charges,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.05,70,,,percent of total billed charges,70% of total billed charges,226.13,75,,,percent of total billed charges,75% of total billed charges,150.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,241.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,301.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,211.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,301.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,301.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,301.5,
WIRE CERCLAGE,3631802,CDM,278,RC,C1713,HCPCS,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
RESERVOIR OMMAYA,3631805,CDM,278,RC,C1889,HCPCS,Outpatient,,,575,345,,103.5,18,,,percent of total billed charges,pays at 18% of total charges,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.5,70,,,percent of total billed charges,70% of total billed charges,431.25,75,,,percent of total billed charges,75% of total billed charges,287.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,575,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,99.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,402.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,345,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,402.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,575,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.1,575,
HUMERAL TRAY,3631808,CDM,278,RC,C1776,HCPCS,Outpatient,,,5418.74,3251.24,,975.37,18,,,percent of total billed charges,pays at 18% of total charges,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,975.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3793.12,70,,,percent of total billed charges,70% of total billed charges,4064.06,75,,,percent of total billed charges,75% of total billed charges,2709.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4334.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3251.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5418.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,933.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2438.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3793.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3251.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2059.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3793.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2601,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5418.74,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5418.74,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.12,5418.74,
PLATE DHS BARREL,3631809,CDM,278,RC,,,Outpatient,,,776,465.6,,139.68,18,,,percent of total billed charges,pays at 18% of total charges,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,388,50,,,percent of total billed charges,pays at 50% of total billed charges,543.2,70,,,percent of total billed charges,70% of total billed charges,582,75,,,percent of total billed charges,75% of total billed charges,388,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,620.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,465.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,776,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,543.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,465.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,543.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,776,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,776,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.6,776,
PLATE BROAD 12H TO 16H,3631812,CDM,278,RC,C1713,HCPCS,Outpatient,,,1868,1120.8,,336.24,18,,,percent of total billed charges,pays at 18% of total charges,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1307.6,70,,,percent of total billed charges,70% of total billed charges,1401,75,,,percent of total billed charges,75% of total billed charges,934,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1868,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,321.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1307.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1120.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,709.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1307.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1868,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1868,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.72,1868,
PENILE CATH URETHRAL MEAS,3631819,CDM,272,RC,,,Outpatient,,,247,148.2,,44.46,18,,,percent of total billed charges,pays at 18% of total charges,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.5,50,,,percent of total billed charges,pays at 50% of total billed charges,172.9,70,,,percent of total billed charges,70% of total billed charges,185.25,75,,,percent of total billed charges,75% of total billed charges,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,172.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,222.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,247,
BRUSH CYTOLOGY,3631822,CDM,272,RC,,,Outpatient,,,110.25,66.15,,19.85,18,,,percent of total billed charges,pays at 18% of total charges,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.13,50,,,percent of total billed charges,pays at 50% of total billed charges,77.18,70,,,percent of total billed charges,70% of total billed charges,82.69,75,,,percent of total billed charges,75% of total billed charges,55.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,77.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,110.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,110.25,
KIT ACCESSORY,3631823,CDM,272,RC,,,Outpatient,,,149,89.4,,26.82,18,,,percent of total billed charges,pays at 18% of total charges,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.5,50,,,percent of total billed charges,pays at 50% of total billed charges,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,149,
BOOTS AND ANCHORS,3631824,CDM,278,RC,C1713,HCPCS,Outpatient,,,175.5,105.3,,31.59,18,,,percent of total billed charges,pays at 18% of total charges,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.85,70,,,percent of total billed charges,70% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,87.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,175.5,
WRENCHES & SCREWS,3631825,CDM,272,RC,,,Outpatient,,,275,165,,49.5,18,,,percent of total billed charges,pays at 18% of total charges,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,275,
FEMORAL STEM BOLT,3631830,CDM,278,RC,C1713,HCPCS,Outpatient,,,367,220.2,,66.06,18,,,percent of total billed charges,pays at 18% of total charges,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.9,70,,,percent of total billed charges,70% of total billed charges,275.25,75,,,percent of total billed charges,75% of total billed charges,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,256.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,367,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,367,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.51,367,
IMPLANT METACARPAL,3631831,CDM,278,RC,L8630,HCPCS,Outpatient,,,1853.08,1111.85,,333.55,18,,,percent of total billed charges,pays at 18% of total charges,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,926.54,50,,,percent of total billed charges,pays at 50% of total billed charges,1297.16,70,,,percent of total billed charges,70% of total billed charges,1389.81,75,,,percent of total billed charges,75% of total billed charges,926.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1482.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1111.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1853.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,319.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,833.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1297.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1111.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,704.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1297.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1853.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1853.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.38,1853.08,
IMPLANT METACARPAL,3631834,CDM,278,RC,L8630,HCPCS,Outpatient,,,2678,1606.8,,482.04,18,,,percent of total billed charges,pays at 18% of total charges,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1339,50,,,percent of total billed charges,pays at 50% of total billed charges,1874.6,70,,,percent of total billed charges,70% of total billed charges,2008.5,75,,,percent of total billed charges,75% of total billed charges,1339,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1606.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2678,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,461.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1205.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1874.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1606.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1017.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1874.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2678,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2678,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.64,2678,
CORD CIRCON DISP,3631837,CDM,272,RC,,,Outpatient,,,74.5,44.7,,13.41,18,,,percent of total billed charges,pays at 18% of total charges,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.25,50,,,percent of total billed charges,pays at 50% of total billed charges,52.15,70,,,percent of total billed charges,70% of total billed charges,55.88,75,,,percent of total billed charges,75% of total billed charges,37.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,74.5,
KIT ORTHOPEDIC,3631851,CDM,272,RC,,,Outpatient,,,927,556.2,,166.86,18,,,percent of total billed charges,pays at 18% of total charges,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.5,50,,,percent of total billed charges,pays at 50% of total billed charges,648.9,70,,,percent of total billed charges,70% of total billed charges,695.25,75,,,percent of total billed charges,75% of total billed charges,463.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,741.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,709.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,648.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,556.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,352.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,648.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,927,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,834.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.26,927,
SCREW CANN,3631883,CDM,278,RC,C1713,HCPCS,Outpatient,,,500,300,,90,18,,,percent of total billed charges,pays at 18% of total charges,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350,70,,,percent of total billed charges,70% of total billed charges,375,75,,,percent of total billed charges,75% of total billed charges,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.35,500,
ROD 1/4,3631888,CDM,278,RC,C1713,HCPCS,Outpatient,,,757,454.2,,136.26,18,,,percent of total billed charges,pays at 18% of total charges,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.9,70,,,percent of total billed charges,70% of total billed charges,567.75,75,,,percent of total billed charges,75% of total billed charges,378.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,605.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,454.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,757,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,529.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,454.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,529.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,757,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,757,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.62,757,
BONE CEMENT 40GR,3631891,CDM,278,RC,C1713,HCPCS,Outpatient,,,199.5,119.7,,35.91,18,,,percent of total billed charges,pays at 18% of total charges,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,70,,,percent of total billed charges,70% of total billed charges,149.63,75,,,percent of total billed charges,75% of total billed charges,99.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,139.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,199.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,199.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.26,199.5,
SLEEVE RESORBABLE,3631896,CDM,278,RC,,,Outpatient,,,553.5,332.1,,99.63,18,,,percent of total billed charges,pays at 18% of total charges,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.75,50,,,percent of total billed charges,pays at 50% of total billed charges,387.45,70,,,percent of total billed charges,70% of total billed charges,415.13,75,,,percent of total billed charges,75% of total billed charges,276.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,553.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,387.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,387.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,553.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,553.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.73,553.5,
SCREW VARIABLE 4.0,3631936,CDM,278,RC,C1713,HCPCS,Outpatient,,,605,363,,108.9,18,,,percent of total billed charges,pays at 18% of total charges,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.5,70,,,percent of total billed charges,70% of total billed charges,453.75,75,,,percent of total billed charges,75% of total billed charges,302.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,605,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,423.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,605,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,605,
SCREW VARIABLE 4.5,3631937,CDM,278,RC,C1713,HCPCS,Outpatient,,,637.5,382.5,,114.75,18,,,percent of total billed charges,pays at 18% of total charges,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.25,70,,,percent of total billed charges,70% of total billed charges,478.13,75,,,percent of total billed charges,75% of total billed charges,318.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,510,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,446.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,446.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,637.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,637.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.9,637.5,
DRILL BIT CANN SM,3631938,CDM,272,RC,,,Outpatient,,,575.5,345.3,,103.59,18,,,percent of total billed charges,pays at 18% of total charges,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.75,50,,,percent of total billed charges,pays at 50% of total billed charges,402.85,70,,,percent of total billed charges,70% of total billed charges,431.63,75,,,percent of total billed charges,75% of total billed charges,287.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,460.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,440.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,402.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,345.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,402.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,575.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,517.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.18,575.5,
BONE CORT BLK 8X14X11MM,3631943,CDM,278,RC,,,Outpatient,,,2085.5,1251.3,,375.39,18,,,percent of total billed charges,pays at 18% of total charges,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1042.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1459.85,70,,,percent of total billed charges,70% of total billed charges,1564.13,75,,,percent of total billed charges,75% of total billed charges,1042.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1668.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1251.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2085.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1459.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1251.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,792.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1459.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2085.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2085.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.8,2085.5,
END CAP TI,3631954,CDM,278,RC,C1713,HCPCS,Outpatient,,,303.5,182.1,,54.63,18,,,percent of total billed charges,pays at 18% of total charges,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.45,70,,,percent of total billed charges,70% of total billed charges,227.63,75,,,percent of total billed charges,75% of total billed charges,151.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,303.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,303.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.56,303.5,
PLATE SACRAL 1 LEVEL,3631980,CDM,278,RC,,,Outpatient,,,6746.5,4047.9,,1214.37,18,,,percent of total billed charges,pays at 18% of total charges,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1214.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3373.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4722.55,70,,,percent of total billed charges,70% of total billed charges,5059.88,75,,,percent of total billed charges,75% of total billed charges,3373.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5397.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4047.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6746.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3035.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4722.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4047.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2563.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4722.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3238.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6746.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6746.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1057.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.18,6746.5,
TORQUE VISE,3631999,CDM,272,RC,,,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
TOOL DISSECTING AM25,3632000,CDM,272,RC,,,Outpatient,,,226,135.6,,40.68,18,,,percent of total billed charges,pays at 18% of total charges,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113,50,,,percent of total billed charges,pays at 50% of total billed charges,158.2,70,,,percent of total billed charges,70% of total billed charges,169.5,75,,,percent of total billed charges,75% of total billed charges,113,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,158.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,158.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,226,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,203.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.41,226,
K WIRE TROCAR THRD,3632002,CDM,272,RC,C1769,HCPCS,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
FILTER PALL,3632015,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
COMPONENT ARTICULAR REV,3632016,CDM,278,RC,C1776,HCPCS,Outpatient,,,7307.3,4384.38,,1315.31,18,,,percent of total billed charges,pays at 18% of total charges,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1315.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5115.11,70,,,percent of total billed charges,70% of total billed charges,5480.48,75,,,percent of total billed charges,75% of total billed charges,3653.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5845.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4384.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7307.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1259.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3288.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5115.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4384.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2776.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5115.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3507.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7307.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7307.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1145.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145.05,7307.3,
ARTICULAR COMPONENT,3632017,CDM,278,RC,C1776,HCPCS,Outpatient,,,3100,1860,,558,18,,,percent of total billed charges,pays at 18% of total charges,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,558,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170,70,,,percent of total billed charges,70% of total billed charges,2325,75,,,percent of total billed charges,75% of total billed charges,1550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1860,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3100,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,534.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1395,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2170,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1860,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1178,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2170,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.77,3100,
PENILE RESERVOIR,3632024,CDM,278,RC,C1813,HCPCS,Outpatient,,,2314,1388.4,,416.52,18,,,percent of total billed charges,pays at 18% of total charges,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.8,70,,,percent of total billed charges,70% of total billed charges,1735.5,75,,,percent of total billed charges,75% of total billed charges,1157,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1851.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1388.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2314,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,398.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1041.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1619.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1388.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,879.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1619.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1110.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2314,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2314,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.6,2314,
BLADE GRAFT HARVEST,3632054,CDM,272,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
BANDAGE ESMARK,3632064,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
ELECTRODE TWIST PR,3632066,CDM,272,RC,,,Outpatient,,,562,337.2,,101.16,18,,,percent of total billed charges,pays at 18% of total charges,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,281,50,,,percent of total billed charges,pays at 50% of total billed charges,393.4,70,,,percent of total billed charges,70% of total billed charges,421.5,75,,,percent of total billed charges,75% of total billed charges,281,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,449.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,393.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,337.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,393.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,562,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,505.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.07,562,
ELECTRODE KNIFE,3632068,CDM,272,RC,,,Outpatient,,,619.5,371.7,,111.51,18,,,percent of total billed charges,pays at 18% of total charges,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.75,50,,,percent of total billed charges,pays at 50% of total billed charges,433.65,70,,,percent of total billed charges,70% of total billed charges,464.63,75,,,percent of total billed charges,75% of total billed charges,309.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,495.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,371.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,433.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,371.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,235.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,433.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,619.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,557.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.08,619.5,
ELECTRODE LOOP,3632069,CDM,272,RC,,,Outpatient,,,232,139.2,,41.76,18,,,percent of total billed charges,pays at 18% of total charges,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116,50,,,percent of total billed charges,pays at 50% of total billed charges,162.4,70,,,percent of total billed charges,70% of total billed charges,174,75,,,percent of total billed charges,75% of total billed charges,116,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,232,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,208.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,232,
ELECTRODE LOOP,3632070,CDM,272,RC,,,Outpatient,,,650,390,,117,18,,,percent of total billed charges,pays at 18% of total charges,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325,50,,,percent of total billed charges,pays at 50% of total billed charges,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,325,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,497.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,585,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
ELECTRODE ROLLERBALL,3632072,CDM,272,RC,,,Outpatient,,,268,160.8,,48.24,18,,,percent of total billed charges,pays at 18% of total charges,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134,50,,,percent of total billed charges,pays at 50% of total billed charges,187.6,70,,,percent of total billed charges,70% of total billed charges,201,75,,,percent of total billed charges,75% of total billed charges,134,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,160.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,187.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,187.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,268,
BLADE FULL RADIUS,3632073,CDM,272,RC,,,Outpatient,,,197.5,118.5,,35.55,18,,,percent of total billed charges,pays at 18% of total charges,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,98.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,197.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,197.5,
PLATE DORSAL RADIUS,3632074,CDM,278,RC,C1713,HCPCS,Outpatient,,,1193,715.8,,214.74,18,,,percent of total billed charges,pays at 18% of total charges,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.1,70,,,percent of total billed charges,70% of total billed charges,894.75,75,,,percent of total billed charges,75% of total billed charges,596.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,954.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,715.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,835.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,715.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,835.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.94,1193,
PLATE CANN ANGL BLADE,3632075,CDM,278,RC,C1713,HCPCS,Outpatient,,,1223,733.8,,220.14,18,,,percent of total billed charges,pays at 18% of total charges,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,856.1,70,,,percent of total billed charges,70% of total billed charges,917.25,75,,,percent of total billed charges,75% of total billed charges,611.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,978.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,733.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1223,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,856.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,733.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,464.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,856.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1223,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1223,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.64,1223,
GRASPING FORCEP,3632091,CDM,272,RC,,,Outpatient,,,459,275.4,,82.62,18,,,percent of total billed charges,pays at 18% of total charges,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.5,50,,,percent of total billed charges,pays at 50% of total billed charges,321.3,70,,,percent of total billed charges,70% of total billed charges,344.25,75,,,percent of total billed charges,75% of total billed charges,229.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,321.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,321.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,459,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,413.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.93,459,
NAIL TIBIAL,3632097,CDM,278,RC,C1713,HCPCS,Outpatient,,,2800,1680,,504,18,,,percent of total billed charges,pays at 18% of total charges,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,504,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,70,,,percent of total billed charges,70% of total billed charges,2100,75,,,percent of total billed charges,75% of total billed charges,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1064,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.76,2800,
RELOAD LAP CUTTER ENDOPATH,3633001,CDM,272,RC,,,Outpatient,,,452.5,271.5,,81.45,18,,,percent of total billed charges,pays at 18% of total charges,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.25,50,,,percent of total billed charges,pays at 50% of total billed charges,316.75,70,,,percent of total billed charges,70% of total billed charges,339.38,75,,,percent of total billed charges,75% of total billed charges,226.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,362,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,316.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,452.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,452.5,
RELOAD LAP CUTTER ENDOPATH,3633002,CDM,272,RC,,,Outpatient,,,354,212.4,,63.72,18,,,percent of total billed charges,pays at 18% of total charges,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177,50,,,percent of total billed charges,pays at 50% of total billed charges,247.8,70,,,percent of total billed charges,70% of total billed charges,265.5,75,,,percent of total billed charges,75% of total billed charges,177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,354,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,318.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.47,354,
LAP CUTTER ARTICUL.ENDO,3633003,CDM,272,RC,,,Outpatient,,,853.5,512.1,,153.63,18,,,percent of total billed charges,pays at 18% of total charges,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.75,50,,,percent of total billed charges,pays at 50% of total billed charges,597.45,70,,,percent of total billed charges,70% of total billed charges,640.13,75,,,percent of total billed charges,75% of total billed charges,426.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,682.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,652.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,597.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,512.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,597.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,853.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,768.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.74,853.5,
TROCAR LAP SLEEVE THOR,3633004,CDM,272,RC,,,Outpatient,,,84,50.4,,15.12,18,,,percent of total billed charges,pays at 18% of total charges,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,50,,,percent of total billed charges,pays at 50% of total billed charges,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,75.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,84,
NEEDLE INSUFFLATION,3633006,CDM,272,RC,,,Outpatient,,,108,64.8,,19.44,18,,,percent of total billed charges,pays at 18% of total charges,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,50,,,percent of total billed charges,pays at 50% of total billed charges,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,108,
LAP TROCAR ENDOPATH 12MM,3633008,CDM,272,RC,,,Outpatient,,,278.5,167.1,,50.13,18,,,percent of total billed charges,pays at 18% of total charges,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.25,50,,,percent of total billed charges,pays at 50% of total billed charges,194.95,70,,,percent of total billed charges,70% of total billed charges,208.88,75,,,percent of total billed charges,75% of total billed charges,139.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,250.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,278.5,
SYS DISSECTN BALLN TROCAR AND ACCESSRY,3633009,CDM,272,RC,,,Outpatient,,,632,379.2,,113.76,18,,,percent of total billed charges,pays at 18% of total charges,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316,50,,,percent of total billed charges,pays at 50% of total billed charges,442.4,70,,,percent of total billed charges,70% of total billed charges,474,75,,,percent of total billed charges,75% of total billed charges,316,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,505.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,483.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,442.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,379.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,442.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,632,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,568.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.03,632,
NAIL FEMORAL RECON LAT ENT,3633023,CDM,278,RC,C1713,HCPCS,Outpatient,,,2269,1361.4,,408.42,18,,,percent of total billed charges,pays at 18% of total charges,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1588.3,70,,,percent of total billed charges,70% of total billed charges,1701.75,75,,,percent of total billed charges,75% of total billed charges,1134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1361.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2269,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,390.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1588.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1361.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,862.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1588.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1089.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.55,2269,
PIN STEINMAN,3633049,CDM,278,RC,C1713,HCPCS,Outpatient,,,200,120,,36,18,,,percent of total billed charges,pays at 18% of total charges,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,200,
TIP FAN SPRAY,3633054,CDM,272,RC,,,Outpatient,,,40,24,,7.2,18,,,percent of total billed charges,pays at 18% of total charges,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20,50,,,percent of total billed charges,pays at 50% of total billed charges,28,70,,,percent of total billed charges,70% of total billed charges,30,75,,,percent of total billed charges,75% of total billed charges,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,40,
CATH RECTAL,3633075,CDM,272,RC,,,Outpatient,,,105,63,,18.9,18,,,percent of total billed charges,pays at 18% of total charges,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,50,,,percent of total billed charges,pays at 50% of total billed charges,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,105,
TUBING Y,3633076,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
STOPCOCK 3 WAY EXT,3633083,CDM,272,RC,,,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
FEMORAL HEAD,3633087,CDM,278,RC,C1776,HCPCS,Outpatient,,,2801.5,1680.9,,504.27,18,,,percent of total billed charges,pays at 18% of total charges,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,504.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1961.05,70,,,percent of total billed charges,70% of total billed charges,2101.13,75,,,percent of total billed charges,75% of total billed charges,1400.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2241.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2801.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1961.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1680.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1064.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1961.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2801.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2801.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439,2801.5,
FIXATOR ELBOW HINGED,3633090,CDM,278,RC,C1713,HCPCS,Outpatient,,,2115.5,1269.3,,380.79,18,,,percent of total billed charges,pays at 18% of total charges,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,380.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.85,70,,,percent of total billed charges,70% of total billed charges,1586.63,75,,,percent of total billed charges,75% of total billed charges,1057.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1692.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1269.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2115.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,364.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1480.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1269.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,803.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1480.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.5,2115.5,
TOOMEY SYRINGE,3633113,CDM,272,RC,,,Outpatient,,,16,9.6,,2.88,18,,,percent of total billed charges,pays at 18% of total charges,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8,50,,,percent of total billed charges,pays at 50% of total billed charges,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,16,
NEEDLE & BLADE GUARD,3633125,CDM,272,RC,,,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
KIT ABSORABLE ORTHOSORB,3633134,CDM,278,RC,C1713,HCPCS,Outpatient,,,1259,755.4,,226.62,18,,,percent of total billed charges,pays at 18% of total charges,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,881.3,70,,,percent of total billed charges,70% of total billed charges,944.25,75,,,percent of total billed charges,75% of total billed charges,629.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1007.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,755.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1259,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,216.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,566.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,881.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,755.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,478.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,881.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1259,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1259,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.29,1259,
CAUTERY TIPOLISHER,3633140,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
K WIRE TROCAR PT,3633147,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
SPLINT NASAL SILICONE,3633150,CDM,272,RC,,,Outpatient,,,94.5,56.7,,17.01,18,,,percent of total billed charges,pays at 18% of total charges,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.25,50,,,percent of total billed charges,pays at 50% of total billed charges,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,47.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,94.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,94.5,
PUTTY 1CC,3633151,CDM,278,RC,C9359,HCPCS,Outpatient,,,461,276.6,,82.98,18,,,percent of total billed charges,pays at 18% of total charges,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.5,50,,,percent of total billed charges,pays at 50% of total billed charges,322.7,70,,,percent of total billed charges,70% of total billed charges,345.75,75,,,percent of total billed charges,75% of total billed charges,230.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,368.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,461,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,322.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,276.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,322.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,461,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,461,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.24,461,
PUTTY 5CC,3633152,CDM,278,RC,C9359,HCPCS,Outpatient,,,1629.5,977.7,,293.31,18,,,percent of total billed charges,pays at 18% of total charges,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,293.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,814.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1140.65,70,,,percent of total billed charges,70% of total billed charges,1222.13,75,,,percent of total billed charges,75% of total billed charges,814.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1303.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,977.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1629.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,280.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1140.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,977.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,619.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1140.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1629.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1629.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.34,1629.5,
BUTTON NASAL SEPTAL,3633153,CDM,272,RC,,,Outpatient,,,346.5,207.9,,62.37,18,,,percent of total billed charges,pays at 18% of total charges,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.25,50,,,percent of total billed charges,pays at 50% of total billed charges,242.55,70,,,percent of total billed charges,70% of total billed charges,259.88,75,,,percent of total billed charges,75% of total billed charges,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,242.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,242.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,346.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,311.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.3,346.5,
SCREW LCKG,3633157,CDM,278,RC,C1713,HCPCS,Outpatient,,,257.5,154.5,,46.35,18,,,percent of total billed charges,pays at 18% of total charges,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.25,70,,,percent of total billed charges,70% of total billed charges,193.13,75,,,percent of total billed charges,75% of total billed charges,128.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,180.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,257.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,257.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.35,257.5,
BONE HARVESTING TUBE DISP,3633158,CDM,272,RC,,,Outpatient,,,1040,624,,187.2,18,,,percent of total billed charges,pays at 18% of total charges,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,1040,
BONE FLAP,3633159,CDM,278,RC,,,Outpatient,,,14625,8775,,2632.5,18,,,percent of total billed charges,pays at 18% of total charges,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2632.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7312.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10237.5,70,,,percent of total billed charges,70% of total billed charges,10968.75,75,,,percent of total billed charges,75% of total billed charges,7312.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8775,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14625,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6581.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10237.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8775,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5557.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10237.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7020,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2291.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2291.74,14625,
STAPLER LINEAR 30 3.5,3633177,CDM,272,RC,,,Outpatient,,,530.5,318.3,,95.49,18,,,percent of total billed charges,pays at 18% of total charges,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.25,50,,,percent of total billed charges,pays at 50% of total billed charges,371.35,70,,,percent of total billed charges,70% of total billed charges,397.88,75,,,percent of total billed charges,75% of total billed charges,265.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,530.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,477.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.13,530.5,
MULTI CLIP APPLIER MED,3633178,CDM,272,RC,,,Outpatient,,,275,165,,49.5,18,,,percent of total billed charges,pays at 18% of total charges,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,275,
LINEAR STAPLER 60 3.5 DLU,3633179,CDM,272,RC,,,Outpatient,,,201.5,120.9,,36.27,18,,,percent of total billed charges,pays at 18% of total charges,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.75,50,,,percent of total billed charges,pays at 50% of total billed charges,141.05,70,,,percent of total billed charges,70% of total billed charges,151.13,75,,,percent of total billed charges,75% of total billed charges,100.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,201.5,
SHEARS LAP COAGULATING,3633182,CDM,272,RC,,,Outpatient,,,842,505.2,,151.56,18,,,percent of total billed charges,pays at 18% of total charges,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421,50,,,percent of total billed charges,pays at 50% of total billed charges,589.4,70,,,percent of total billed charges,70% of total billed charges,631.5,75,,,percent of total billed charges,75% of total billed charges,421,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,673.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,505.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,644.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,589.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,505.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,319.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,589.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,842,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,757.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.94,842,
MARLEX PLUG,3633188,CDM,278,RC,C1781,HCPCS,Outpatient,,,530.5,318.3,,95.49,18,,,percent of total billed charges,pays at 18% of total charges,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.35,70,,,percent of total billed charges,70% of total billed charges,397.88,75,,,percent of total billed charges,75% of total billed charges,265.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,530.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,91.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,530.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,530.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.13,530.5,
CLIP APPLIER LG,3633193,CDM,272,RC,,,Outpatient,,,464,278.4,,83.52,18,,,percent of total billed charges,pays at 18% of total charges,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232,50,,,percent of total billed charges,pays at 50% of total billed charges,324.8,70,,,percent of total billed charges,70% of total billed charges,348,75,,,percent of total billed charges,75% of total billed charges,232,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,354.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,464,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,417.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.71,464,
CLIP APPLIER XL,3633194,CDM,272,RC,,,Outpatient,,,464,278.4,,83.52,18,,,percent of total billed charges,pays at 18% of total charges,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,232,50,,,percent of total billed charges,pays at 50% of total billed charges,324.8,70,,,percent of total billed charges,70% of total billed charges,348,75,,,percent of total billed charges,75% of total billed charges,232,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,371.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,354.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,176.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,324.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,464,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,417.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.71,464,
ACETABULAR SHELL,3633195,CDM,278,RC,C1776,HCPCS,Outpatient,,,6144.01,3686.41,,1105.92,18,,,percent of total billed charges,pays at 18% of total charges,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1105.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4300.81,70,,,percent of total billed charges,70% of total billed charges,4608.01,75,,,percent of total billed charges,75% of total billed charges,3072.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4915.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3686.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6144.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1058.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2764.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4300.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3686.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2334.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4300.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2949.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6144.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6144.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,962.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.77,6144.01,
LINEAR CUTTER 75 THICK DL,3633197,CDM,272,RC,,,Outpatient,,,426.5,255.9,,76.77,18,,,percent of total billed charges,pays at 18% of total charges,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.25,50,,,percent of total billed charges,pays at 50% of total billed charges,298.55,70,,,percent of total billed charges,70% of total billed charges,319.88,75,,,percent of total billed charges,75% of total billed charges,213.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,298.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,298.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,426.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,383.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.83,426.5,
LINEAR CUTTER 75 REG,3633198,CDM,272,RC,,,Outpatient,,,625,375,,112.5,18,,,percent of total billed charges,pays at 18% of total charges,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,312.5,50,,,percent of total billed charges,pays at 50% of total billed charges,437.5,70,,,percent of total billed charges,70% of total billed charges,468.75,75,,,percent of total billed charges,75% of total billed charges,312.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,375,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,478.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,437.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,375,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,437.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,562.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.94,625,
LINEAR CUTTER 75 REG DLU,3633199,CDM,272,RC,,,Outpatient,,,426.5,255.9,,76.77,18,,,percent of total billed charges,pays at 18% of total charges,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.25,50,,,percent of total billed charges,pays at 50% of total billed charges,298.55,70,,,percent of total billed charges,70% of total billed charges,319.88,75,,,percent of total billed charges,75% of total billed charges,213.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,341.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,298.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,298.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,426.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,383.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.83,426.5,
CLIP APPLIER MED,3633200,CDM,272,RC,,,Outpatient,,,215.5,129.3,,38.79,18,,,percent of total billed charges,pays at 18% of total charges,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.75,50,,,percent of total billed charges,pays at 50% of total billed charges,150.85,70,,,percent of total billed charges,70% of total billed charges,161.63,75,,,percent of total billed charges,75% of total billed charges,107.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,150.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,150.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,215.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,193.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.77,215.5,
MULTI CLIP APPLIER LRG,3633203,CDM,272,RC,,,Outpatient,,,216.5,129.9,,38.97,18,,,percent of total billed charges,pays at 18% of total charges,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.25,50,,,percent of total billed charges,pays at 50% of total billed charges,151.55,70,,,percent of total billed charges,70% of total billed charges,162.38,75,,,percent of total billed charges,75% of total billed charges,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,216.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,194.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.93,216.5,
LINEAR CUTTER 75 THICK,3633204,CDM,272,RC,,,Outpatient,,,853.5,512.1,,153.63,18,,,percent of total billed charges,pays at 18% of total charges,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.75,50,,,percent of total billed charges,pays at 50% of total billed charges,597.45,70,,,percent of total billed charges,70% of total billed charges,640.13,75,,,percent of total billed charges,75% of total billed charges,426.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,682.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,512.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,652.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,597.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,512.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,597.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,853.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,768.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.74,853.5,
CLAMP ADJ,3633219,CDM,272,RC,,,Outpatient,,,1521.5,912.9,,273.87,18,,,percent of total billed charges,pays at 18% of total charges,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,760.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1065.05,70,,,percent of total billed charges,70% of total billed charges,1141.13,75,,,percent of total billed charges,75% of total billed charges,760.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1217.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,912.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1163.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1065.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,912.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,578.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1065.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1521.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1369.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.42,1521.5,
K WIRE 2.5,3633242,CDM,272,RC,,,Outpatient,,,168,100.8,,30.24,18,,,percent of total billed charges,pays at 18% of total charges,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84,50,,,percent of total billed charges,pays at 50% of total billed charges,117.6,70,,,percent of total billed charges,70% of total billed charges,126,75,,,percent of total billed charges,75% of total billed charges,84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.33,168,
PLATE NARROW LCP 10H - 16H,3633244,CDM,278,RC,C1713,HCPCS,Outpatient,,,1121,672.6,,201.78,18,,,percent of total billed charges,pays at 18% of total charges,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.7,70,,,percent of total billed charges,70% of total billed charges,840.75,75,,,percent of total billed charges,75% of total billed charges,560.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,896.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,672.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1121,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,784.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,672.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,425.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,784.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1121,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1121,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.66,1121,
LOOPS VASCULAR,3633252,CDM,272,RC,,,Outpatient,,,87.5,52.5,,15.75,18,,,percent of total billed charges,pays at 18% of total charges,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.75,50,,,percent of total billed charges,pays at 50% of total billed charges,61.25,70,,,percent of total billed charges,70% of total billed charges,65.63,75,,,percent of total billed charges,75% of total billed charges,43.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,87.5,
PLATE,3633272,CDM,278,RC,C1713,HCPCS,Outpatient,,,1868,1120.8,,336.24,18,,,percent of total billed charges,pays at 18% of total charges,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1307.6,70,,,percent of total billed charges,70% of total billed charges,1401,75,,,percent of total billed charges,75% of total billed charges,934,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1494.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1120.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1868,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,321.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1307.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1120.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,709.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1307.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1868,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1868,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.72,1868,
SCREW CANN,3633275,CDM,278,RC,C1713,HCPCS,Outpatient,,,479,287.4,,86.22,18,,,percent of total billed charges,pays at 18% of total charges,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.3,70,,,percent of total billed charges,70% of total billed charges,359.25,75,,,percent of total billed charges,75% of total billed charges,239.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,383.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,479,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,479,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,479,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.06,479,
LINEAR CUTTER 55 REG,3633288,CDM,272,RC,,,Outpatient,,,533.5,320.1,,96.03,18,,,percent of total billed charges,pays at 18% of total charges,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.75,50,,,percent of total billed charges,pays at 50% of total billed charges,373.45,70,,,percent of total billed charges,70% of total billed charges,400.13,75,,,percent of total billed charges,75% of total billed charges,266.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,426.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,373.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,320.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,373.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,533.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,480.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.6,533.5,
LINEAR CUTTER 55 REG DLU,3633289,CDM,272,RC,,,Outpatient,,,272,163.2,,48.96,18,,,percent of total billed charges,pays at 18% of total charges,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136,50,,,percent of total billed charges,pays at 50% of total billed charges,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,136,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,272,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,272,
FORCEP BICOAG BIPOLAR CUT,3633308,CDM,272,RC,,,Outpatient,,,833,499.8,,149.94,18,,,percent of total billed charges,pays at 18% of total charges,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.5,50,,,percent of total billed charges,pays at 50% of total billed charges,583.1,70,,,percent of total billed charges,70% of total billed charges,624.75,75,,,percent of total billed charges,75% of total billed charges,416.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,666.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,499.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,499.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,583.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,833,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,749.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.53,833,
CATH VENTRICULAR 35CM,3633309,CDM,272,RC,,,Outpatient,,,211,126.6,,37.98,18,,,percent of total billed charges,pays at 18% of total charges,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.5,50,,,percent of total billed charges,pays at 50% of total billed charges,147.7,70,,,percent of total billed charges,70% of total billed charges,158.25,75,,,percent of total billed charges,75% of total billed charges,105.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,211,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.06,211,
STAPLER LINEAR 60 4.8,3633319,CDM,272,RC,,,Outpatient,,,416,249.6,,74.88,18,,,percent of total billed charges,pays at 18% of total charges,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208,50,,,percent of total billed charges,pays at 50% of total billed charges,291.2,70,,,percent of total billed charges,70% of total billed charges,312,75,,,percent of total billed charges,75% of total billed charges,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,374.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.19,416,
RELOAD LINEAR CUTTER,3633321,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
RELOAD STAPLER 60MM 4.8,3633322,CDM,272,RC,,,Outpatient,,,140.5,84.3,,25.29,18,,,percent of total billed charges,pays at 18% of total charges,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.25,50,,,percent of total billed charges,pays at 50% of total billed charges,98.35,70,,,percent of total billed charges,70% of total billed charges,105.38,75,,,percent of total billed charges,75% of total billed charges,70.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,98.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,126.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.02,140.5,
BLADE SAW,3633331,CDM,272,RC,,,Outpatient,,,128,76.8,,23.04,18,,,percent of total billed charges,pays at 18% of total charges,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64,50,,,percent of total billed charges,pays at 50% of total billed charges,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,128,
BLADE BOVIE EDGE INS COAT,3633336,CDM,272,RC,,,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
EDGE INSUL CTD NEEDLE,3633337,CDM,272,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
STEM CENTRALIZER,3633340,CDM,278,RC,,,Outpatient,,,240,144,,43.2,18,,,percent of total billed charges,pays at 18% of total charges,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120,50,,,percent of total billed charges,pays at 50% of total billed charges,168,70,,,percent of total billed charges,70% of total billed charges,180,75,,,percent of total billed charges,75% of total billed charges,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.61,240,
TRAY EPIDURAL CONT,3633345,CDM,272,RC,,,Outpatient,,,161.5,96.9,,29.07,18,,,percent of total billed charges,pays at 18% of total charges,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.75,50,,,percent of total billed charges,pays at 50% of total billed charges,113.05,70,,,percent of total billed charges,70% of total billed charges,121.13,75,,,percent of total billed charges,75% of total billed charges,80.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,161.5,
SCREW CANN 6.5,3633351,CDM,278,RC,C1713,HCPCS,Outpatient,,,404,242.4,,72.72,18,,,percent of total billed charges,pays at 18% of total charges,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.8,70,,,percent of total billed charges,70% of total billed charges,303,75,,,percent of total billed charges,75% of total billed charges,202,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,404,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.31,404,
K WIRE THRD,3633352,CDM,278,RC,C1713,HCPCS,Outpatient,,,84,50.4,,15.12,18,,,percent of total billed charges,pays at 18% of total charges,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.16,84,
CLAMP CONNECTING,3633353,CDM,272,RC,,,Outpatient,,,1041.5,624.9,,187.47,18,,,percent of total billed charges,pays at 18% of total charges,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520.75,50,,,percent of total billed charges,pays at 50% of total billed charges,729.05,70,,,percent of total billed charges,70% of total billed charges,781.13,75,,,percent of total billed charges,75% of total billed charges,520.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,833.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,624.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,796.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,729.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,729.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1041.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,937.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,1041.5,
BOLT LCKG,3633367,CDM,278,RC,C1713,HCPCS,Outpatient,,,307.5,184.5,,55.35,18,,,percent of total billed charges,pays at 18% of total charges,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.25,70,,,percent of total billed charges,70% of total billed charges,230.63,75,,,percent of total billed charges,75% of total billed charges,153.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,307.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,215.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,307.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,307.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.19,307.5,
FEMORAL COMPONENT,3633377,CDM,278,RC,C1776,HCPCS,Outpatient,,,4199,2519.4,,755.82,18,,,percent of total billed charges,pays at 18% of total charges,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,755.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2939.3,70,,,percent of total billed charges,70% of total billed charges,3149.25,75,,,percent of total billed charges,75% of total billed charges,2099.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2519.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4199,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,723.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1889.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2939.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2519.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1595.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2939.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2015.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4199,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4199,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,657.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.98,4199,
DIST CENTRALIZER,3633378,CDM,278,RC,,,Outpatient,,,103,61.8,,18.54,18,,,percent of total billed charges,pays at 18% of total charges,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.5,50,,,percent of total billed charges,pays at 50% of total billed charges,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,103,
FEMORAL HEAD,3633379,CDM,278,RC,C1776,HCPCS,Outpatient,,,751,450.6,,135.18,18,,,percent of total billed charges,pays at 18% of total charges,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.7,70,,,percent of total billed charges,70% of total billed charges,563.25,75,,,percent of total billed charges,75% of total billed charges,375.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,751,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,525.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,450.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,525.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,751,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,751,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.68,751,
STAPLER LINEAR VASC 30,3633381,CDM,272,RC,,,Outpatient,,,446.5,267.9,,80.37,18,,,percent of total billed charges,pays at 18% of total charges,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.25,50,,,percent of total billed charges,pays at 50% of total billed charges,312.55,70,,,percent of total billed charges,70% of total billed charges,334.88,75,,,percent of total billed charges,75% of total billed charges,223.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,357.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,267.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,312.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,446.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,401.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.97,446.5,
STAPLER LINEAR 30V DLU,3633382,CDM,272,RC,,,Outpatient,,,191,114.6,,34.38,18,,,percent of total billed charges,pays at 18% of total charges,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.5,50,,,percent of total billed charges,pays at 50% of total billed charges,133.7,70,,,percent of total billed charges,70% of total billed charges,143.25,75,,,percent of total billed charges,75% of total billed charges,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,133.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,191,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,171.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.93,191,
GRAFT WALL STD,3633384,CDM,278,RC,C1768,HCPCS,Outpatient,,,832.5,499.5,,149.85,18,,,percent of total billed charges,pays at 18% of total charges,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.75,70,,,percent of total billed charges,70% of total billed charges,624.38,75,,,percent of total billed charges,75% of total billed charges,416.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,666,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,499.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,832.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,582.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,499.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,582.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,832.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,832.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.45,832.5,
MESH COMPOSIX LGE,3633388,CDM,278,RC,C1781,HCPCS,Outpatient,,,1402,841.2,,252.36,18,,,percent of total billed charges,pays at 18% of total charges,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,981.4,70,,,percent of total billed charges,70% of total billed charges,1051.5,75,,,percent of total billed charges,75% of total billed charges,701,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,841.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1402,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,241.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,981.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,841.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,532.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,981.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1402,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1402,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.69,1402,
KIT TRANSGASTRIC JEJUNAL,3633395,CDM,272,RC,,,Outpatient,,,852.5,511.5,,153.45,18,,,percent of total billed charges,pays at 18% of total charges,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,426.25,50,,,percent of total billed charges,pays at 50% of total billed charges,596.75,70,,,percent of total billed charges,70% of total billed charges,639.38,75,,,percent of total billed charges,75% of total billed charges,426.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,682,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,511.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,652.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,596.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,511.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,596.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,852.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,767.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.59,852.5,
DRILL BIT ADJ CIRC,3633399,CDM,272,RC,,,Outpatient,,,428.5,257.1,,77.13,18,,,percent of total billed charges,pays at 18% of total charges,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.25,50,,,percent of total billed charges,pays at 50% of total billed charges,299.95,70,,,percent of total billed charges,70% of total billed charges,321.38,75,,,percent of total billed charges,75% of total billed charges,214.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,299.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,428.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,385.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.15,428.5,
DRILL BIT  NAVIGATION,3633400,CDM,272,RC,,,Outpatient,,,1487,892.2,,267.66,18,,,percent of total billed charges,pays at 18% of total charges,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,743.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1040.9,70,,,percent of total billed charges,70% of total billed charges,1115.25,75,,,percent of total billed charges,75% of total billed charges,743.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1189.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,892.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1137.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1040.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,892.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,565.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1040.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1487,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1338.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.01,1487,
FEMORAL COMPONENT UNI,3633408,CDM,278,RC,C1776,HCPCS,Outpatient,,,2885.5,1731.3,,519.39,18,,,percent of total billed charges,pays at 18% of total charges,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.85,70,,,percent of total billed charges,70% of total billed charges,2164.13,75,,,percent of total billed charges,75% of total billed charges,1442.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2308.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1731.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2885.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,497.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1298.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2019.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1731.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1096.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2019.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1385.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2885.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2885.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.16,2885.5,
STAPLER SKIN DISP,3633411,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
COUPLING FOR BONE SPACER,3633412,CDM,278,RC,C1776,HCPCS,Outpatient,,,10986.3,6591.78,,1977.53,18,,,percent of total billed charges,pays at 18% of total charges,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1977.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7690.41,70,,,percent of total billed charges,70% of total billed charges,8239.73,75,,,percent of total billed charges,75% of total billed charges,5493.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8789.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6591.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10986.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1892.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4943.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7690.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6591.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4174.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7690.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5273.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10986.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10986.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1721.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1721.55,10986.3,
RELOAD LINEAR 30MM 3.5,3633421,CDM,272,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
STAPLER ARTICUL 55 4.8,3633422,CDM,272,RC,,,Outpatient,,,830.5,498.3,,149.49,18,,,percent of total billed charges,pays at 18% of total charges,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,415.25,50,,,percent of total billed charges,pays at 50% of total billed charges,581.35,70,,,percent of total billed charges,70% of total billed charges,622.88,75,,,percent of total billed charges,75% of total billed charges,415.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,664.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,498.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,635.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,581.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,498.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,581.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,830.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,747.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.14,830.5,
PLATE BROAD LCP TI,3633429,CDM,278,RC,C1713,HCPCS,Outpatient,,,404.5,242.7,,72.81,18,,,percent of total billed charges,pays at 18% of total charges,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.15,70,,,percent of total billed charges,70% of total billed charges,303.38,75,,,percent of total billed charges,75% of total billed charges,202.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,323.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,404.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,283.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,404.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,404.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.39,404.5,
SCREW LCKG 6.0,3633432,CDM,278,RC,C1713,HCPCS,Outpatient,,,303.5,182.1,,54.63,18,,,percent of total billed charges,pays at 18% of total charges,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.45,70,,,percent of total billed charges,70% of total billed charges,227.63,75,,,percent of total billed charges,75% of total billed charges,151.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,242.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,303.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,303.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.56,303.5,
STAPLER LINEAR 30 4.8,3633440,CDM,272,RC,,,Outpatient,,,402,241.2,,72.36,18,,,percent of total billed charges,pays at 18% of total charges,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201,50,,,percent of total billed charges,pays at 50% of total billed charges,281.4,70,,,percent of total billed charges,70% of total billed charges,301.5,75,,,percent of total billed charges,75% of total billed charges,201,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,307.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,361.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.99,402,
NAIL FEMORAL CANN RETRO,3633441,CDM,278,RC,C1713,HCPCS,Outpatient,,,2269,1361.4,,408.42,18,,,percent of total billed charges,pays at 18% of total charges,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1588.3,70,,,percent of total billed charges,70% of total billed charges,1701.75,75,,,percent of total billed charges,75% of total billed charges,1134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1815.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1361.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2269,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,390.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1588.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1361.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,862.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1588.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1089.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.55,2269,
NAIL FEMORAL CANN,3633446,CDM,278,RC,C1713,HCPCS,Outpatient,,,1780,1068,,320.4,18,,,percent of total billed charges,pays at 18% of total charges,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1246,70,,,percent of total billed charges,70% of total billed charges,1335,75,,,percent of total billed charges,75% of total billed charges,890,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1068,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1780,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,306.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1246,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1068,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,676.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1246,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.93,1780,
SPLNT PLASTER X-FAST 3X15,3633447,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
SPLNT PLASTR X-FAST 4X15,3633448,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
EDGE SMOKE ROCKER PENCIL,3633454,CDM,272,RC,,,Outpatient,,,62,37.2,,11.16,18,,,percent of total billed charges,pays at 18% of total charges,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,62,
OATS HARVESTER SET,3633457,CDM,272,RC,,,Outpatient,,,1129,677.4,,203.22,18,,,percent of total billed charges,pays at 18% of total charges,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,564.5,50,,,percent of total billed charges,pays at 50% of total billed charges,790.3,70,,,percent of total billed charges,70% of total billed charges,846.75,75,,,percent of total billed charges,75% of total billed charges,564.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,903.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,677.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,863.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,790.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,677.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,790.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1129,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1016.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.91,1129,
BLADE SAW,3633469,CDM,272,RC,,,Outpatient,,,124,74.4,,22.32,18,,,percent of total billed charges,pays at 18% of total charges,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62,50,,,percent of total billed charges,pays at 50% of total billed charges,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,124,
ROD CARBON,3633471,CDM,272,RC,C1713,HCPCS,Outpatient,,,256,153.6,,46.08,18,,,percent of total billed charges,pays at 18% of total charges,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,128,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,256,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.12,256,
TISSUE TRAP,3633474,CDM,272,RC,,,Outpatient,,,64,38.4,,11.52,18,,,percent of total billed charges,pays at 18% of total charges,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32,50,,,percent of total billed charges,pays at 50% of total billed charges,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,64,
IMPLANT SPHERE,3633479,CDM,278,RC,,,Outpatient,,,1037.5,622.5,,186.75,18,,,percent of total billed charges,pays at 18% of total charges,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,518.75,50,,,percent of total billed charges,pays at 50% of total billed charges,726.25,70,,,percent of total billed charges,70% of total billed charges,778.13,75,,,percent of total billed charges,75% of total billed charges,518.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,830,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,622.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1037.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,726.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,622.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,726.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1037.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1037.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.58,1037.5,
TIBIAL INSERT,3633494,CDM,278,RC,C1776,HCPCS,Outpatient,,,3030.5,1818.3,,545.49,18,,,percent of total billed charges,pays at 18% of total charges,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,545.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2121.35,70,,,percent of total billed charges,70% of total billed charges,2272.88,75,,,percent of total billed charges,75% of total billed charges,1515.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1818.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3030.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,522.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2121.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1818.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1151.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2121.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1454.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3030.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3030.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,474.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.88,3030.5,
CLAMP COMBINATION,3633511,CDM,272,RC,,,Outpatient,,,1135,681,,204.3,18,,,percent of total billed charges,pays at 18% of total charges,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567.5,50,,,percent of total billed charges,pays at 50% of total billed charges,794.5,70,,,percent of total billed charges,70% of total billed charges,851.25,75,,,percent of total billed charges,75% of total billed charges,567.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,681,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,868.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,794.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,681,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,431.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,794.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1135,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1021.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.85,1135,
STAYS SURGICAL,3633512,CDM,272,RC,,,Outpatient,,,23,13.8,,4.14,18,,,percent of total billed charges,pays at 18% of total charges,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.5,50,,,percent of total billed charges,pays at 50% of total billed charges,16.1,70,,,percent of total billed charges,70% of total billed charges,17.25,75,,,percent of total billed charges,75% of total billed charges,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,23,
CURVTEK CARTRIDGE MED,3633550,CDM,278,RC,,,Outpatient,,,1193,715.8,,214.74,18,,,percent of total billed charges,pays at 18% of total charges,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.5,50,,,percent of total billed charges,pays at 50% of total billed charges,835.1,70,,,percent of total billed charges,70% of total billed charges,894.75,75,,,percent of total billed charges,75% of total billed charges,596.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,954.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,715.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,835.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,715.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,835.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.94,1193,
CATH FILIFORM SPIRAL,3633555,CDM,272,RC,,,Outpatient,,,31.5,18.9,,5.67,18,,,percent of total billed charges,pays at 18% of total charges,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.75,50,,,percent of total billed charges,pays at 50% of total billed charges,22.05,70,,,percent of total billed charges,70% of total billed charges,23.63,75,,,percent of total billed charges,75% of total billed charges,15.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.94,31.5,
FEMORAL STEM,3633566,CDM,278,RC,C1776,HCPCS,Outpatient,,,5825.5,3495.3,,1048.59,18,,,percent of total billed charges,pays at 18% of total charges,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1048.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4077.85,70,,,percent of total billed charges,70% of total billed charges,4369.13,75,,,percent of total billed charges,75% of total billed charges,2912.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4660.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3495.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5825.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1003.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2621.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4077.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3495.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2213.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4077.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5825.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5825.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,912.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,912.86,5825.5,
SUTURE ASST INSTRUMENT,3633576,CDM,272,RC,,,Outpatient,,,576.5,345.9,,103.77,18,,,percent of total billed charges,pays at 18% of total charges,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.25,50,,,percent of total billed charges,pays at 50% of total billed charges,403.55,70,,,percent of total billed charges,70% of total billed charges,432.38,75,,,percent of total billed charges,75% of total billed charges,288.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,461.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,403.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,345.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,403.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,576.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,518.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.34,576.5,
RELOAD SUTURE ASST,3633577,CDM,272,RC,,,Outpatient,,,103,61.8,,18.54,18,,,percent of total billed charges,pays at 18% of total charges,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.5,50,,,percent of total billed charges,pays at 50% of total billed charges,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,103,
RELOAD STAPLER 90MM,3633587,CDM,272,RC,,,Outpatient,,,422,253.2,,75.96,18,,,percent of total billed charges,pays at 18% of total charges,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211,50,,,percent of total billed charges,pays at 50% of total billed charges,295.4,70,,,percent of total billed charges,70% of total billed charges,316.5,75,,,percent of total billed charges,75% of total billed charges,211,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,295.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,295.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,422,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,379.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.13,422,
FEMORAL COMPONENT,3633621,CDM,278,RC,C1776,HCPCS,Outpatient,,,7840.5,4704.3,,1411.29,18,,,percent of total billed charges,pays at 18% of total charges,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1411.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5488.35,70,,,percent of total billed charges,70% of total billed charges,5880.38,75,,,percent of total billed charges,75% of total billed charges,3920.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6272.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4704.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7840.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1350.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3528.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5488.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4704.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2979.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5488.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3763.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7840.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7840.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.61,7840.5,
ROD,3633637,CDM,278,RC,C1713,HCPCS,Outpatient,,,814.15,488.49,,146.55,18,,,percent of total billed charges,pays at 18% of total charges,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.91,70,,,percent of total billed charges,70% of total billed charges,610.61,75,,,percent of total billed charges,75% of total billed charges,407.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,651.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,488.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,814.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,140.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,569.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,569.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,814.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,814.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,814.15,
MESH COMPOSIX LGE,3633654,CDM,278,RC,C1781,HCPCS,Outpatient,,,2594.5,1556.7,,467.01,18,,,percent of total billed charges,pays at 18% of total charges,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1816.15,70,,,percent of total billed charges,70% of total billed charges,1945.88,75,,,percent of total billed charges,75% of total billed charges,1297.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2075.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1556.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2594.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,447.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1816.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1556.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,985.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1816.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2594.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2594.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.56,2594.5,
CATH FOLEY IRRIG,3633658,CDM,272,RC,,,Outpatient,,,130,78,,23.4,18,,,percent of total billed charges,pays at 18% of total charges,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65,50,,,percent of total billed charges,pays at 50% of total billed charges,91,70,,,percent of total billed charges,70% of total billed charges,97.5,75,,,percent of total billed charges,75% of total billed charges,65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,130,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,117,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.37,130,
KIT LAP GASTRO TUBE,3633659,CDM,272,RC,,,Outpatient,,,350.25,210.15,,63.05,18,,,percent of total billed charges,pays at 18% of total charges,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.13,50,,,percent of total billed charges,pays at 50% of total billed charges,245.18,70,,,percent of total billed charges,70% of total billed charges,262.69,75,,,percent of total billed charges,75% of total billed charges,175.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,350.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,315.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.88,350.25,
SCREW,3633662,CDM,278,RC,C1713,HCPCS,Outpatient,,,224.5,134.7,,40.41,18,,,percent of total billed charges,pays at 18% of total charges,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.15,70,,,percent of total billed charges,70% of total billed charges,168.38,75,,,percent of total billed charges,75% of total billed charges,112.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,224.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,224.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,224.5,
NAIL ANKLE ARTHRODESIS,3633664,CDM,278,RC,C1713,HCPCS,Outpatient,,,2177,1306.2,,391.86,18,,,percent of total billed charges,pays at 18% of total charges,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1523.9,70,,,percent of total billed charges,70% of total billed charges,1632.75,75,,,percent of total billed charges,75% of total billed charges,1088.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1741.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1306.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2177,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,375.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1523.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1306.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,827.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1523.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2177,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2177,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.14,2177,
FEMORAL HEAD,3633670,CDM,278,RC,C1776,HCPCS,Outpatient,,,1156,693.6,,208.08,18,,,percent of total billed charges,pays at 18% of total charges,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,208.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.2,70,,,percent of total billed charges,70% of total billed charges,867,75,,,percent of total billed charges,75% of total billed charges,578,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,924.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,693.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1156,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,199.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,809.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,693.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,439.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,809.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1156,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1156,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,181.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.15,1156,
HOLE ELIMINATOR,3633672,CDM,278,RC,C1713,HCPCS,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
SURGICAL TISSUE POUCH,3633678,CDM,272,RC,,,Outpatient,,,135.5,81.3,,24.39,18,,,percent of total billed charges,pays at 18% of total charges,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.75,50,,,percent of total billed charges,pays at 50% of total billed charges,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,67.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,135.5,
PATCH HERNIA CIRCLE,3633691,CDM,278,RC,C1781,HCPCS,Outpatient,,,594.5,356.7,,107.01,18,,,percent of total billed charges,pays at 18% of total charges,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.15,70,,,percent of total billed charges,70% of total billed charges,445.88,75,,,percent of total billed charges,75% of total billed charges,297.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,475.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,356.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,416.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,356.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,416.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,594.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,594.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.16,594.5,
PATCH VENTRIO HERNIA,3633692,CDM,278,RC,C1781,HCPCS,Outpatient,,,925,555,,166.5,18,,,percent of total billed charges,pays at 18% of total charges,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.5,70,,,percent of total billed charges,70% of total billed charges,693.75,75,,,percent of total billed charges,75% of total billed charges,462.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,740,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,555,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,925,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,159.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,647.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,555,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,647.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,925,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,925,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.95,925,
NAIL FEMORAL CANN LAT ENTRY,3633693,CDM,278,RC,C1713,HCPCS,Outpatient,,,2150.5,1290.3,,387.09,18,,,percent of total billed charges,pays at 18% of total charges,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1505.35,70,,,percent of total billed charges,70% of total billed charges,1612.88,75,,,percent of total billed charges,75% of total billed charges,1075.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1720.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1290.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2150.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,370.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1505.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1290.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,817.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1505.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1032.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2150.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2150.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,336.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.98,2150.5,
DRILL BIT 3.5 CANN,3633697,CDM,272,RC,,,Outpatient,,,716,429.6,,128.88,18,,,percent of total billed charges,pays at 18% of total charges,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358,50,,,percent of total billed charges,pays at 50% of total billed charges,501.2,70,,,percent of total billed charges,70% of total billed charges,537,75,,,percent of total billed charges,75% of total billed charges,358,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,547.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,429.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,716,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,644.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.2,716,
ARTHROWAND TURBOVAC,3633807,CDM,272,RC,,,Outpatient,,,533.5,320.1,,96.03,18,,,percent of total billed charges,pays at 18% of total charges,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.75,50,,,percent of total billed charges,pays at 50% of total billed charges,373.45,70,,,percent of total billed charges,70% of total billed charges,400.13,75,,,percent of total billed charges,75% of total billed charges,266.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,426.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,373.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,320.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,373.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,533.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,480.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.6,533.5,
PIN STEINMAN THRD,3633845,CDM,278,RC,C1713,HCPCS,Outpatient,,,214,128.4,,38.52,18,,,percent of total billed charges,pays at 18% of total charges,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,214,
BAG DRAINAGE VENTRICULAR,3633854,CDM,272,RC,,,Outpatient,,,296,177.6,,53.28,18,,,percent of total billed charges,pays at 18% of total charges,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148,50,,,percent of total billed charges,pays at 50% of total billed charges,207.2,70,,,percent of total billed charges,70% of total billed charges,222,75,,,percent of total billed charges,75% of total billed charges,148,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,296,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.38,296,
PLATE L OBLIQUE,3633863,CDM,278,RC,C1713,HCPCS,Outpatient,,,93.5,56.1,,16.83,18,,,percent of total billed charges,pays at 18% of total charges,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.45,70,,,percent of total billed charges,70% of total billed charges,70.13,75,,,percent of total billed charges,75% of total billed charges,46.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,65.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.65,93.5,
STAPLER LINEAR,3633866,CDM,272,RC,,,Outpatient,,,361,216.6,,64.98,18,,,percent of total billed charges,pays at 18% of total charges,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.5,50,,,percent of total billed charges,pays at 50% of total billed charges,252.7,70,,,percent of total billed charges,70% of total billed charges,270.75,75,,,percent of total billed charges,75% of total billed charges,180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,252.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,361,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.57,361,
FEMORAL CEMENT RESTRICTOR,3633876,CDM,272,RC,,,Outpatient,,,192,115.2,,34.56,18,,,percent of total billed charges,pays at 18% of total charges,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96,50,,,percent of total billed charges,pays at 50% of total billed charges,134.4,70,,,percent of total billed charges,70% of total billed charges,144,75,,,percent of total billed charges,75% of total billed charges,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,172.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,192,
FEMORAL STEM,3633877,CDM,278,RC,C1776,HCPCS,Outpatient,,,4979,2987.4,,896.22,18,,,percent of total billed charges,pays at 18% of total charges,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,896.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3485.3,70,,,percent of total billed charges,70% of total billed charges,3734.25,75,,,percent of total billed charges,75% of total billed charges,2489.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3983.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2987.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4979,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,857.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3485.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2987.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1892.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3485.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2389.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4979,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4979,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,780.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.21,4979,
PLATE WRIST FUSION,3633906,CDM,278,RC,C1713,HCPCS,Outpatient,,,1024,614.4,,184.32,18,,,percent of total billed charges,pays at 18% of total charges,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.8,70,,,percent of total billed charges,70% of total billed charges,768,75,,,percent of total billed charges,75% of total billed charges,512,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,819.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,614.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1024,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,716.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,614.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,389.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,716.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1024,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1024,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.46,1024,
PENILE OCCLUSIVE CUFF,3633915,CDM,278,RC,C1815,HCPCS,Outpatient,,,3812,2287.2,,686.16,18,,,percent of total billed charges,pays at 18% of total charges,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,686.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2668.4,70,,,percent of total billed charges,70% of total billed charges,2859,75,,,percent of total billed charges,75% of total billed charges,1906,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3049.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2287.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3812,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,656.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1715.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2668.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2287.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1448.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2668.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1829.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3812,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3812,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.34,3812,
PENILE PRESSURE REG BALLOON,3633916,CDM,278,RC,C1815,HCPCS,Outpatient,,,2803.5,1682.1,,504.63,18,,,percent of total billed charges,pays at 18% of total charges,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,504.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1962.45,70,,,percent of total billed charges,70% of total billed charges,2102.63,75,,,percent of total billed charges,75% of total billed charges,1401.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2242.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1682.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2803.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,483.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1962.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1682.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1065.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1962.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2803.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2803.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.31,2803.5,
PENILE CONTROL PUMP,3633917,CDM,278,RC,C1815,HCPCS,Outpatient,,,4407,2644.2,,793.26,18,,,percent of total billed charges,pays at 18% of total charges,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,793.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3084.9,70,,,percent of total billed charges,70% of total billed charges,3305.25,75,,,percent of total billed charges,75% of total billed charges,2203.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2644.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4407,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,759.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1983.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3084.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2644.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1674.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3084.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2115.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,690.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,690.58,4407,
PENILE ACCESSORY KIT,3633918,CDM,278,RC,,,Outpatient,,,992.5,595.5,,178.65,18,,,percent of total billed charges,pays at 18% of total charges,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,496.25,50,,,percent of total billed charges,pays at 50% of total billed charges,694.75,70,,,percent of total billed charges,70% of total billed charges,744.38,75,,,percent of total billed charges,75% of total billed charges,496.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,794,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,595.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,694.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,595.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,377.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,694.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,992.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,992.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.52,992.5,
KIT NEPHROMAX,3633924,CDM,272,RC,,,Outpatient,,,606,363.6,,109.08,18,,,percent of total billed charges,pays at 18% of total charges,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303,50,,,percent of total billed charges,pays at 50% of total billed charges,424.2,70,,,percent of total billed charges,70% of total billed charges,454.5,75,,,percent of total billed charges,75% of total billed charges,303,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,424.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,424.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,606,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,545.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,606,
PLATE CONDYLAR LCP TI,3633937,CDM,278,RC,C1713,HCPCS,Outpatient,,,1046,627.6,,188.28,18,,,percent of total billed charges,pays at 18% of total charges,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732.2,70,,,percent of total billed charges,70% of total billed charges,784.5,75,,,percent of total billed charges,75% of total billed charges,523,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,836.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,627.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1046,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,180.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,732.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,627.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,732.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1046,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1046,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.91,1046,
IMPLANT MAMMARY TISS EXPA,3633939,CDM,278,RC,,,Outpatient,,,2322.5,1393.5,,418.05,18,,,percent of total billed charges,pays at 18% of total charges,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1161.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1625.75,70,,,percent of total billed charges,70% of total billed charges,1741.88,75,,,percent of total billed charges,75% of total billed charges,1161.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1858,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1393.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2322.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1625.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1393.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,882.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1625.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2322.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2322.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.94,2322.5,
TISSUE EXPANDERS MAMMARY,3633940,CDM,278,RC,,,Outpatient,,,2582,1549.2,,464.76,18,,,percent of total billed charges,pays at 18% of total charges,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,464.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1291,50,,,percent of total billed charges,pays at 50% of total billed charges,1807.4,70,,,percent of total billed charges,70% of total billed charges,1936.5,75,,,percent of total billed charges,75% of total billed charges,1291,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2065.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1549.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2582,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1807.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1549.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,981.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1807.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2582,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2582,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.6,2582,
CLIP APPLIER 5MM,3633942,CDM,272,RC,,,Outpatient,,,631,378.6,,113.58,18,,,percent of total billed charges,pays at 18% of total charges,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.5,50,,,percent of total billed charges,pays at 50% of total billed charges,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,315.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,482.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,631,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,567.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,631,
COMP FEMORAL PREASSMBL,3633969,CDM,278,RC,C1776,HCPCS,Outpatient,,,13462,8077.2,,2423.16,18,,,percent of total billed charges,pays at 18% of total charges,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2423.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9423.4,70,,,percent of total billed charges,70% of total billed charges,10096.5,75,,,percent of total billed charges,75% of total billed charges,6731,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10769.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8077.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13462,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2319.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6057.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9423.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8077.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5115.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9423.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6461.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13462,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13462,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2109.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2109.5,13462,
ELECTRODE LOOP,3633975,CDM,272,RC,,,Outpatient,,,212,127.2,,38.16,18,,,percent of total billed charges,pays at 18% of total charges,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106,50,,,percent of total billed charges,pays at 50% of total billed charges,148.4,70,,,percent of total billed charges,70% of total billed charges,159,75,,,percent of total billed charges,75% of total billed charges,106,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,169.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,148.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,148.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,190.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.22,212,
HEART URCHIN,3633982,CDM,272,RC,,,Outpatient,,,968.5,581.1,,174.33,18,,,percent of total billed charges,pays at 18% of total charges,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,484.25,50,,,percent of total billed charges,pays at 50% of total billed charges,677.95,70,,,percent of total billed charges,70% of total billed charges,726.38,75,,,percent of total billed charges,75% of total billed charges,484.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,774.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,581.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,740.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,677.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,581.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,677.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,968.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,871.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.76,968.5,
OCTOPUS 2,3633985,CDM,272,RC,,,Outpatient,,,2399.5,1439.7,,431.91,18,,,percent of total billed charges,pays at 18% of total charges,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,431.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1199.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1679.65,70,,,percent of total billed charges,70% of total billed charges,1799.63,75,,,percent of total billed charges,75% of total billed charges,1199.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1919.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1439.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1835.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1679.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1439.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,911.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1679.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1151.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2399.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2159.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376,2399.5,
BLOWER MIST,3633986,CDM,272,RC,,,Outpatient,,,197.5,118.5,,35.55,18,,,percent of total billed charges,pays at 18% of total charges,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,98.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,197.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,197.5,
TIP EYE TURBO ABS 45DEG,3633995,CDM,272,RC,,,Outpatient,,,224.5,134.7,,40.41,18,,,percent of total billed charges,pays at 18% of total charges,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.25,50,,,percent of total billed charges,pays at 50% of total billed charges,157.15,70,,,percent of total billed charges,70% of total billed charges,168.38,75,,,percent of total billed charges,75% of total billed charges,112.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,224.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,202.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,224.5,
TIBIAL INSERT,3633999,CDM,278,RC,C1776,HCPCS,Outpatient,,,2232.5,1339.5,,401.85,18,,,percent of total billed charges,pays at 18% of total charges,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.75,70,,,percent of total billed charges,70% of total billed charges,1674.38,75,,,percent of total billed charges,75% of total billed charges,1116.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1786,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1339.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2232.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,384.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1562.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1339.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,848.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1562.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2232.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2232.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.83,2232.5,
FEMORAL STEM,3634000,CDM,278,RC,C1776,HCPCS,Outpatient,,,11131,6678.6,,2003.58,18,,,percent of total billed charges,pays at 18% of total charges,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2003.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7791.7,70,,,percent of total billed charges,70% of total billed charges,8348.25,75,,,percent of total billed charges,75% of total billed charges,5565.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6678.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11131,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1917.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5008.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7791.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6678.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4229.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7791.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5342.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11131,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11131,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1744.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1744.23,11131,
SHUNT DENVER PAK ASCITIES,3634014,CDM,278,RC,,,Outpatient,,,2066.5,1239.9,,371.97,18,,,percent of total billed charges,pays at 18% of total charges,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,371.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1033.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1446.55,70,,,percent of total billed charges,70% of total billed charges,1549.88,75,,,percent of total billed charges,75% of total billed charges,1033.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1239.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2066.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1446.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1239.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1446.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2066.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2066.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.82,2066.5,
LENS GLIDE IOL,3634016,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
TRAY UROLOGIST,3634017,CDM,272,RC,,,Outpatient,,,421.25,252.75,,75.83,18,,,percent of total billed charges,pays at 18% of total charges,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.63,50,,,percent of total billed charges,pays at 50% of total billed charges,294.88,70,,,percent of total billed charges,70% of total billed charges,315.94,75,,,percent of total billed charges,75% of total billed charges,210.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,337,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,294.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,252.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,294.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,421.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,379.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.01,421.25,
SCREW CANC BONE,3634018,CDM,278,RC,C1713,HCPCS,Outpatient,,,247,148.2,,44.46,18,,,percent of total billed charges,pays at 18% of total charges,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.9,70,,,percent of total billed charges,70% of total billed charges,185.25,75,,,percent of total billed charges,75% of total billed charges,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,172.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,247,
ROD CARBON LNG,3634129,CDM,278,RC,C1713,HCPCS,Outpatient,,,327.5,196.5,,58.95,18,,,percent of total billed charges,pays at 18% of total charges,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.25,70,,,percent of total billed charges,70% of total billed charges,245.63,75,,,percent of total billed charges,75% of total billed charges,163.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,262,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,229.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,229.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,327.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.32,327.5,
CINCH,3634133,CDM,272,RC,,,Outpatient,,,908.5,545.1,,163.53,18,,,percent of total billed charges,pays at 18% of total charges,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.25,50,,,percent of total billed charges,pays at 50% of total billed charges,635.95,70,,,percent of total billed charges,70% of total billed charges,681.38,75,,,percent of total billed charges,75% of total billed charges,454.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,726.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,545.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,695,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,635.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,545.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,635.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,908.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,817.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.36,908.5,
CATH THERMACHOICE BALLOON,3634134,CDM,272,RC,,,Outpatient,,,2385.5,1431.3,,429.39,18,,,percent of total billed charges,pays at 18% of total charges,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,429.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1192.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1669.85,70,,,percent of total billed charges,70% of total billed charges,1789.13,75,,,percent of total billed charges,75% of total billed charges,1192.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1908.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1431.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1824.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1073.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1669.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1431.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,906.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1669.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2385.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2146.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.81,2385.5,
DRAIN BLAKE,3634146,CDM,272,RC,C1729,HCPCS,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
PLATE FEMUR,3634155,CDM,278,RC,C1713,HCPCS,Outpatient,,,4415.84,2649.5,,794.85,18,,,percent of total billed charges,pays at 18% of total charges,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,794.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3091.09,70,,,percent of total billed charges,70% of total billed charges,3311.88,75,,,percent of total billed charges,75% of total billed charges,2207.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3532.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2649.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4415.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,760.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1987.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3091.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2649.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1678.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3091.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2119.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4415.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4415.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.96,4415.84,
PLATE RIB,3634161,CDM,278,RC,,,Outpatient,,,3463.2,2077.92,,623.38,18,,,percent of total billed charges,pays at 18% of total charges,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1731.6,50,,,percent of total billed charges,pays at 50% of total billed charges,2424.24,70,,,percent of total billed charges,70% of total billed charges,2597.4,75,,,percent of total billed charges,75% of total billed charges,1731.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2770.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2077.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3463.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1558.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2424.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2077.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1316.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2424.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3463.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3463.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,542.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.68,3463.2,
PLATE,3634163,CDM,278,RC,C1713,HCPCS,Outpatient,,,3003,1801.8,,540.54,18,,,percent of total billed charges,pays at 18% of total charges,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,540.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2102.1,70,,,percent of total billed charges,70% of total billed charges,2252.25,75,,,percent of total billed charges,75% of total billed charges,1501.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2402.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1801.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3003,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,517.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2102.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1801.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1141.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2102.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1441.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3003,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3003,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.57,3003,
PLATE,3634165,CDM,278,RC,C1713,HCPCS,Outpatient,,,2611.5,1566.9,,470.07,18,,,percent of total billed charges,pays at 18% of total charges,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1828.05,70,,,percent of total billed charges,70% of total billed charges,1958.63,75,,,percent of total billed charges,75% of total billed charges,1305.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2089.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1566.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2611.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,449.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1828.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1566.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1828.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1253.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2611.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2611.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.22,2611.5,
SCREW CONICAL LNG,3634174,CDM,278,RC,C1713,HCPCS,Outpatient,,,434.5,260.7,,78.21,18,,,percent of total billed charges,pays at 18% of total charges,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.15,70,,,percent of total billed charges,70% of total billed charges,325.88,75,,,percent of total billed charges,75% of total billed charges,217.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,347.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,434.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,304.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,434.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,434.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.09,434.5,
LEAD PISCES QUAD,3634176,CDM,278,RC,C1778,HCPCS,Outpatient,,,3997.5,2398.5,,719.55,18,,,percent of total billed charges,pays at 18% of total charges,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,719.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2798.25,70,,,percent of total billed charges,70% of total billed charges,2998.13,75,,,percent of total billed charges,75% of total billed charges,1998.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3198,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2398.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3997.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,688.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1798.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2798.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2398.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1519.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2798.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1918.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3997.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3997.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,626.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.41,3997.5,
FILTER VENA CAVA,3634178,CDM,278,RC,C1880,HCPCS,Outpatient,,,2776,1665.6,,499.68,18,,,percent of total billed charges,pays at 18% of total charges,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,499.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1943.2,70,,,percent of total billed charges,70% of total billed charges,2082,75,,,percent of total billed charges,75% of total billed charges,1388,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1665.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2776,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,478.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1943.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1665.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1054.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1943.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1332.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2776,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2776,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435,2776,
PLATE ATLANTIS,3634180,CDM,278,RC,,,Outpatient,,,2351,1410.6,,423.18,18,,,percent of total billed charges,pays at 18% of total charges,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,423.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1175.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1645.7,70,,,percent of total billed charges,70% of total billed charges,1763.25,75,,,percent of total billed charges,75% of total billed charges,1175.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1880.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1410.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2351,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1645.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1410.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,893.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1645.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2351,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2351,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,368.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.4,2351,
SUTURE PASSER WORM,3634183,CDM,272,RC,,,Outpatient,,,307.5,184.5,,55.35,18,,,percent of total billed charges,pays at 18% of total charges,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.75,50,,,percent of total billed charges,pays at 50% of total billed charges,215.25,70,,,percent of total billed charges,70% of total billed charges,230.63,75,,,percent of total billed charges,75% of total billed charges,153.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,246,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,235.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,215.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,307.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,276.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.19,307.5,
TUBING INFLOW,3634189,CDM,272,RC,,,Outpatient,,,211,126.6,,37.98,18,,,percent of total billed charges,pays at 18% of total charges,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.5,50,,,percent of total billed charges,pays at 50% of total billed charges,147.7,70,,,percent of total billed charges,70% of total billed charges,158.25,75,,,percent of total billed charges,75% of total billed charges,105.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,211,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.06,211,
GRAFT VASCULAR,3634192,CDM,278,RC,C1768,HCPCS,Outpatient,,,2317.5,1390.5,,417.15,18,,,percent of total billed charges,pays at 18% of total charges,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1622.25,70,,,percent of total billed charges,70% of total billed charges,1738.13,75,,,percent of total billed charges,75% of total billed charges,1158.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1854,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1390.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2317.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,399.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1042.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1622.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1390.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,880.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1622.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1112.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2317.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2317.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,363.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.15,2317.5,
DRILL BIT,3634198,CDM,272,RC,,,Outpatient,,,371.5,222.9,,66.87,18,,,percent of total billed charges,pays at 18% of total charges,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.75,50,,,percent of total billed charges,pays at 50% of total billed charges,260.05,70,,,percent of total billed charges,70% of total billed charges,278.63,75,,,percent of total billed charges,75% of total billed charges,185.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,297.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,222.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,260.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,260.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,371.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,334.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.21,371.5,
FEMORAL COMPONENT,3634203,CDM,278,RC,C1776,HCPCS,Outpatient,,,3779,2267.4,,680.22,18,,,percent of total billed charges,pays at 18% of total charges,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,680.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2645.3,70,,,percent of total billed charges,70% of total billed charges,2834.25,75,,,percent of total billed charges,75% of total billed charges,1889.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3023.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2267.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3779,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,651.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1700.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2645.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2267.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1436.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2645.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1813.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3779,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3779,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.17,3779,
PLATE T,3634204,CDM,278,RC,C1713,HCPCS,Outpatient,,,1086,651.6,,195.48,18,,,percent of total billed charges,pays at 18% of total charges,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.2,70,,,percent of total billed charges,70% of total billed charges,814.5,75,,,percent of total billed charges,75% of total billed charges,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,651.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1086,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,760.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,651.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,760.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1086,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1086,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.18,1086,
ELECTRODE BUTTON VAPOR,3634211,CDM,272,RC,,,Outpatient,,,682.5,409.5,,122.85,18,,,percent of total billed charges,pays at 18% of total charges,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.25,50,,,percent of total billed charges,pays at 50% of total billed charges,477.75,70,,,percent of total billed charges,70% of total billed charges,511.88,75,,,percent of total billed charges,75% of total billed charges,341.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,546,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,409.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,522.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,409.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,477.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,682.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,614.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.95,682.5,
SCREW MICRO,3634213,CDM,278,RC,C1713,HCPCS,Outpatient,,,152.5,91.5,,27.45,18,,,percent of total billed charges,pays at 18% of total charges,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.75,70,,,percent of total billed charges,70% of total billed charges,114.38,75,,,percent of total billed charges,75% of total billed charges,76.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.9,152.5,
PLATE ATLANTIS,3634218,CDM,278,RC,,,Outpatient,,,3003,1801.8,,540.54,18,,,percent of total billed charges,pays at 18% of total charges,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,540.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1501.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2102.1,70,,,percent of total billed charges,70% of total billed charges,2252.25,75,,,percent of total billed charges,75% of total billed charges,1501.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2402.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1801.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3003,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2102.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1801.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1141.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2102.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1441.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3003,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3003,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.57,3003,
DRILL BIT,3634233,CDM,272,RC,,,Outpatient,,,450,270,,81,18,,,percent of total billed charges,pays at 18% of total charges,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,50,,,percent of total billed charges,pays at 50% of total billed charges,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,450,
NEEDLE INTRODUCER,3634235,CDM,272,RC,,,Outpatient,,,450,270,,81,18,,,percent of total billed charges,pays at 18% of total charges,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,50,,,percent of total billed charges,pays at 50% of total billed charges,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,450,
TIBIAL INSERT,3634241,CDM,278,RC,C1776,HCPCS,Outpatient,,,1410,846,,253.8,18,,,percent of total billed charges,pays at 18% of total charges,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987,70,,,percent of total billed charges,70% of total billed charges,1057.5,75,,,percent of total billed charges,75% of total billed charges,705,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,846,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,242.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,987,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,846,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,987,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.95,1410,
KUGEL HERNIA PATCH SM OVAL,3634244,CDM,278,RC,C1781,HCPCS,Outpatient,,,597.5,358.5,,107.55,18,,,percent of total billed charges,pays at 18% of total charges,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.25,70,,,percent of total billed charges,70% of total billed charges,448.13,75,,,percent of total billed charges,75% of total billed charges,298.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,478,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,597.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,418.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,418.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,597.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,597.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.63,597.5,
PATCH HERNIA OVAL,3634245,CDM,278,RC,C1781,HCPCS,Outpatient,,,716,429.6,,128.88,18,,,percent of total billed charges,pays at 18% of total charges,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.2,70,,,percent of total billed charges,70% of total billed charges,537,75,,,percent of total billed charges,75% of total billed charges,358,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,572.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,716,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,429.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,716,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,716,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.2,716,
NAIL FEMORAL DIST,3634251,CDM,278,RC,C1713,HCPCS,Outpatient,,,2395,1437,,431.1,18,,,percent of total billed charges,pays at 18% of total charges,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,431.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1676.5,70,,,percent of total billed charges,70% of total billed charges,1796.25,75,,,percent of total billed charges,75% of total billed charges,1197.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1916,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1437,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2395,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,412.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1077.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1676.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1437,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,910.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1676.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1149.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2395,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2395,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.3,2395,
STENT GLAUCOMA GEL,3634262,CDM,278,RC,C1783,HCPCS,Outpatient,,,2655,1593,,477.9,18,,,percent of total billed charges,pays at 18% of total charges,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1858.5,70,,,percent of total billed charges,70% of total billed charges,1991.25,75,,,percent of total billed charges,75% of total billed charges,1327.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1593,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2655,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,457.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1194.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1858.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1593,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1008.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1858.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1274.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2655,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2655,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.04,2655,
FEMORAL STEM,3634277,CDM,278,RC,C1776,HCPCS,Outpatient,,,1681,1008.6,,302.58,18,,,percent of total billed charges,pays at 18% of total charges,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.7,70,,,percent of total billed charges,70% of total billed charges,1260.75,75,,,percent of total billed charges,75% of total billed charges,840.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1008.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1681,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,289.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,638.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1176.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,806.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1681,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1681,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,263.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.41,1681,
REAMING ROD,3634281,CDM,272,RC,,,Outpatient,,,222.5,133.5,,40.05,18,,,percent of total billed charges,pays at 18% of total charges,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.25,50,,,percent of total billed charges,pays at 50% of total billed charges,155.75,70,,,percent of total billed charges,70% of total billed charges,166.88,75,,,percent of total billed charges,75% of total billed charges,111.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,222.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,200.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.87,222.5,
PLATE ANT CERVICAL,3634312,CDM,278,RC,C1713,HCPCS,Outpatient,,,2072.5,1243.5,,373.05,18,,,percent of total billed charges,pays at 18% of total charges,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1450.75,70,,,percent of total billed charges,70% of total billed charges,1554.38,75,,,percent of total billed charges,75% of total billed charges,1036.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1658,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1243.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2072.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,357.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1450.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1243.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1450.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,994.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2072.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2072.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.76,2072.5,
NEEDLE RETROBULBAR,3634313,CDM,272,RC,,,Outpatient,,,34.5,20.7,,6.21,18,,,percent of total billed charges,pays at 18% of total charges,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.25,50,,,percent of total billed charges,pays at 50% of total billed charges,24.15,70,,,percent of total billed charges,70% of total billed charges,25.88,75,,,percent of total billed charges,75% of total billed charges,17.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.41,34.5,
FEMORAL COMPONENT,3634321,CDM,278,RC,C1776,HCPCS,Outpatient,,,5763.5,3458.1,,1037.43,18,,,percent of total billed charges,pays at 18% of total charges,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1037.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4034.45,70,,,percent of total billed charges,70% of total billed charges,4322.63,75,,,percent of total billed charges,75% of total billed charges,2881.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4610.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3458.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5763.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,993.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2593.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4034.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3458.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2190.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4034.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2766.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5763.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5763.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,903.14,5763.5,
ARTICULAR SURFACE,3634324,CDM,278,RC,C1776,HCPCS,Outpatient,,,2079,1247.4,,374.22,18,,,percent of total billed charges,pays at 18% of total charges,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1455.3,70,,,percent of total billed charges,70% of total billed charges,1559.25,75,,,percent of total billed charges,75% of total billed charges,1039.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1663.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1247.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2079,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,358.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1455.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1247.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,790.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1455.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,997.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2079,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2079,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.78,2079,
OSTEOTOME FLEXIBLE,3634325,CDM,272,RC,,,Outpatient,,,514.5,308.7,,92.61,18,,,percent of total billed charges,pays at 18% of total charges,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.25,50,,,percent of total billed charges,pays at 50% of total billed charges,360.15,70,,,percent of total billed charges,70% of total billed charges,385.88,75,,,percent of total billed charges,75% of total billed charges,257.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,411.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,360.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,514.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,463.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.62,514.5,
KIT BACK PREP,3634327,CDM,272,RC,,,Outpatient,,,1295.5,777.3,,233.19,18,,,percent of total billed charges,pays at 18% of total charges,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,647.75,50,,,percent of total billed charges,pays at 50% of total billed charges,906.85,70,,,percent of total billed charges,70% of total billed charges,971.63,75,,,percent of total billed charges,75% of total billed charges,647.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1036.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,777.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,991.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,906.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,777.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,492.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,906.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1295.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1165.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203,1295.5,
PLATE H 5H,3634330,CDM,278,RC,C1713,HCPCS,Outpatient,,,449,269.4,,80.82,18,,,percent of total billed charges,pays at 18% of total charges,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.3,70,,,percent of total billed charges,70% of total billed charges,336.75,75,,,percent of total billed charges,75% of total billed charges,224.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,449,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,314.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,314.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,449,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,449,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.36,449,
CEMENT RESTRICTOR,3634331,CDM,278,RC,C1713,HCPCS,Outpatient,,,336,201.6,,60.48,18,,,percent of total billed charges,pays at 18% of total charges,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.2,70,,,percent of total billed charges,70% of total billed charges,252,75,,,percent of total billed charges,75% of total billed charges,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,336,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,336,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,336,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,336,
REAMER PROBE,3634332,CDM,272,RC,,,Outpatient,,,224.5,134.7,,40.41,18,,,percent of total billed charges,pays at 18% of total charges,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.25,50,,,percent of total billed charges,pays at 50% of total billed charges,157.15,70,,,percent of total billed charges,70% of total billed charges,168.38,75,,,percent of total billed charges,75% of total billed charges,112.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,224.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,202.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,224.5,
GLOBAL BODY,3634340,CDM,278,RC,C1776,HCPCS,Outpatient,,,4330,2598,,779.4,18,,,percent of total billed charges,pays at 18% of total charges,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,779.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3031,70,,,percent of total billed charges,70% of total billed charges,3247.5,75,,,percent of total billed charges,75% of total billed charges,2165,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2598,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4330,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,746.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1948.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3031,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2598,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1645.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3031,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2078.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4330,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,678.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.51,4330,
DRILL BIT FAST,3634343,CDM,272,RC,,,Outpatient,,,165,99,,29.7,18,,,percent of total billed charges,pays at 18% of total charges,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.5,50,,,percent of total billed charges,pays at 50% of total billed charges,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,82.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,165,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.86,165,
TAP,3634354,CDM,272,RC,,,Outpatient,,,224.5,134.7,,40.41,18,,,percent of total billed charges,pays at 18% of total charges,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.25,50,,,percent of total billed charges,pays at 50% of total billed charges,157.15,70,,,percent of total billed charges,70% of total billed charges,168.38,75,,,percent of total billed charges,75% of total billed charges,112.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,224.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,202.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,224.5,
TAP,3634355,CDM,272,RC,,,Outpatient,,,224.5,134.7,,40.41,18,,,percent of total billed charges,pays at 18% of total charges,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.25,50,,,percent of total billed charges,pays at 50% of total billed charges,157.15,70,,,percent of total billed charges,70% of total billed charges,168.38,75,,,percent of total billed charges,75% of total billed charges,112.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,179.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,224.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,202.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.18,224.5,
PACK PHACO,3634359,CDM,272,RC,,,Outpatient,,,196.5,117.9,,35.37,18,,,percent of total billed charges,pays at 18% of total charges,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.25,50,,,percent of total billed charges,pays at 50% of total billed charges,137.55,70,,,percent of total billed charges,70% of total billed charges,147.38,75,,,percent of total billed charges,75% of total billed charges,98.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,137.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,137.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,196.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,176.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.79,196.5,
AUGMENTATION TIBIAL,3634635,CDM,278,RC,C1776,HCPCS,Outpatient,,,6446.13,3867.68,,1160.3,18,,,percent of total billed charges,pays at 18% of total charges,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1160.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4512.29,70,,,percent of total billed charges,70% of total billed charges,4834.6,75,,,percent of total billed charges,75% of total billed charges,3223.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5156.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3867.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6446.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1110.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2900.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4512.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3867.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2449.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4512.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3094.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6446.13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6446.13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1010.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1010.11,6446.13,
AUGMENTATION CONE,3634636,CDM,278,RC,C1776,HCPCS,Outpatient,,,7583.68,4550.21,,1365.06,18,,,percent of total billed charges,pays at 18% of total charges,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1365.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5308.58,70,,,percent of total billed charges,70% of total billed charges,5687.76,75,,,percent of total billed charges,75% of total billed charges,3791.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6066.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4550.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7583.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1306.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3412.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5308.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4550.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2881.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5308.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3640.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7583.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7583.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1188.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.36,7583.68,
AUGMENTATION CONE,3634638,CDM,278,RC,C1776,HCPCS,Outpatient,,,7280,4368,,1310.4,18,,,percent of total billed charges,pays at 18% of total charges,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1310.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5096,70,,,percent of total billed charges,70% of total billed charges,5460,75,,,percent of total billed charges,75% of total billed charges,3640,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4368,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7280,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1254.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3276,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5096,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4368,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2766.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5096,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3494.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7280,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7280,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1140.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1140.78,7280,
DISC CERVICAL,3634728,CDM,278,RC,,,Outpatient,,,8790.6,5274.36,,1582.31,18,,,percent of total billed charges,pays at 18% of total charges,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1582.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4395.3,50,,,percent of total billed charges,pays at 50% of total billed charges,6153.42,70,,,percent of total billed charges,70% of total billed charges,6592.95,75,,,percent of total billed charges,75% of total billed charges,4395.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7032.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5274.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8790.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3955.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6153.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5274.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3340.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6153.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4219.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8790.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8790.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1377.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1377.49,8790.6,
PACK TRAUMA LF,3634992,CDM,272,RC,,,Outpatient,,,640.5,384.3,,115.29,18,,,percent of total billed charges,pays at 18% of total charges,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,320.25,50,,,percent of total billed charges,pays at 50% of total billed charges,448.35,70,,,percent of total billed charges,70% of total billed charges,480.38,75,,,percent of total billed charges,75% of total billed charges,320.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,512.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,489.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,448.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,384.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,448.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,640.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,576.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.37,640.5,
PLATE COMPOSITE,3635002,CDM,278,RC,C1713,HCPCS,Outpatient,,,325,195,,58.5,18,,,percent of total billed charges,pays at 18% of total charges,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.5,70,,,percent of total billed charges,70% of total billed charges,243.75,75,,,percent of total billed charges,75% of total billed charges,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,227.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,227.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.93,325,
PUMP,3635004,CDM,272,RC,,,Outpatient,,,22526.5,13515.9,,4054.77,18,,,percent of total billed charges,pays at 18% of total charges,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4054.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11263.25,50,,,percent of total billed charges,pays at 50% of total billed charges,15768.55,70,,,percent of total billed charges,70% of total billed charges,16894.88,75,,,percent of total billed charges,75% of total billed charges,11263.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18021.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13515.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17232.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10136.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15768.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13515.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8560.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15768.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10812.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22526.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20273.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3529.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3529.9,22526.5,
DRAIN HEMOVAC LGE,3635144,CDM,272,RC,C1729,HCPCS,Outpatient,,,142,85.2,,25.56,18,,,percent of total billed charges,pays at 18% of total charges,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.4,70,,,percent of total billed charges,70% of total billed charges,106.5,75,,,percent of total billed charges,75% of total billed charges,71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,99.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,127.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,142,
DRAIN HEMOVAC MINI,3635153,CDM,272,RC,C1729,HCPCS,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
VARI-STIM (NERVE LOCATOR),3635178,CDM,272,RC,,,Outpatient,,,86,51.6,,15.48,18,,,percent of total billed charges,pays at 18% of total charges,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43,50,,,percent of total billed charges,pays at 50% of total billed charges,60.2,70,,,percent of total billed charges,70% of total billed charges,64.5,75,,,percent of total billed charges,75% of total billed charges,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,86,
BOVIE SUCTION COAG,3635190,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
GLENOSPHERE,3636424,CDM,278,RC,C1776,HCPCS,Outpatient,,,1369,821.4,,246.42,18,,,percent of total billed charges,pays at 18% of total charges,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.3,70,,,percent of total billed charges,70% of total billed charges,1026.75,75,,,percent of total billed charges,75% of total billed charges,684.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1095.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,821.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1369,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,235.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,958.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,821.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,958.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1369,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1369,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.52,1369,
GLENOSPHERE,3636425,CDM,278,RC,C1713,HCPCS,Outpatient,,,1560,936,,280.8,18,,,percent of total billed charges,pays at 18% of total charges,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092,70,,,percent of total billed charges,70% of total billed charges,1170,75,,,percent of total billed charges,75% of total billed charges,780,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1560,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,592.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1092,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.45,1560,
CUSA SHEAR TIP,3636426,CDM,272,RC,,,Outpatient,,,1281.15,768.69,,230.61,18,,,percent of total billed charges,pays at 18% of total charges,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,230.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,640.58,50,,,percent of total billed charges,pays at 50% of total billed charges,896.81,70,,,percent of total billed charges,70% of total billed charges,960.86,75,,,percent of total billed charges,75% of total billed charges,640.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1024.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,768.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,980.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,486.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,896.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1281.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1153.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.76,1281.15,
STENT POLARIS ALL SZ,3636427,CDM,278,RC,C2617,HCPCS,Outpatient,,,431.5,258.9,,77.67,18,,,percent of total billed charges,pays at 18% of total charges,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.05,70,,,percent of total billed charges,70% of total billed charges,323.63,75,,,percent of total billed charges,75% of total billed charges,215.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,345.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,431.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,302.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,302.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,431.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,431.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.62,431.5,
CUSA TIP EXT CURVED,3636428,CDM,272,RC,,,Outpatient,,,833.62,500.17,,150.05,18,,,percent of total billed charges,pays at 18% of total charges,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.81,50,,,percent of total billed charges,pays at 50% of total billed charges,583.53,70,,,percent of total billed charges,70% of total billed charges,625.22,75,,,percent of total billed charges,75% of total billed charges,416.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,666.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,316.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,583.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,833.62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,750.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.63,833.62,
KIT BALLON DILATOR UROL ALL,3636429,CDM,272,RC,C1726,HCPCS,Outpatient,,,871.5,522.9,,156.87,18,,,percent of total billed charges,pays at 18% of total charges,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.05,70,,,percent of total billed charges,70% of total billed charges,653.63,75,,,percent of total billed charges,75% of total billed charges,435.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,697.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,522.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,150.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,610.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,522.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,331.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,610.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,871.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,784.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.56,871.5,
CUSA SHEAR TIP STERILE,3636430,CDM,272,RC,,,Outpatient,,,222.75,133.65,,40.1,18,,,percent of total billed charges,pays at 18% of total charges,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.38,50,,,percent of total billed charges,pays at 50% of total billed charges,155.93,70,,,percent of total billed charges,70% of total billed charges,167.06,75,,,percent of total billed charges,75% of total billed charges,111.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,222.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,200.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.9,222.75,
SET NEURO IRRIG CASSETTE,3636431,CDM,272,RC,,,Outpatient,,,588,352.8,,105.84,18,,,percent of total billed charges,pays at 18% of total charges,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294,50,,,percent of total billed charges,pays at 50% of total billed charges,411.6,70,,,percent of total billed charges,70% of total billed charges,441,75,,,percent of total billed charges,75% of total billed charges,294,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,449.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,411.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,352.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,411.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,588,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,529.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,588,
CUSA TOURQUE WRENCH STERILE DISP,3636432,CDM,272,RC,,,Outpatient,,,144,86.4,,25.92,18,,,percent of total billed charges,pays at 18% of total charges,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,50,,,percent of total billed charges,pays at 50% of total billed charges,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,144,
STENT URETERAL ALL SZ,3636433,CDM,278,RC,C2617,HCPCS,Outpatient,,,270,162,,48.6,18,,,percent of total billed charges,pays at 18% of total charges,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,70,,,percent of total billed charges,70% of total billed charges,202.5,75,,,percent of total billed charges,75% of total billed charges,135,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,270,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.31,270,
CANISTER SUCTION LG VOL,3636435,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
MANIPULATOR UTERINE DISP,3636436,CDM,272,RC,,,Outpatient,,,252,151.2,,45.36,18,,,percent of total billed charges,pays at 18% of total charges,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,50,,,percent of total billed charges,pays at 50% of total billed charges,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,252,
ANCHOR SUTURE HEALIX PEEK,3636437,CDM,278,RC,C1713,HCPCS,Outpatient,,,482,289.2,,86.76,18,,,percent of total billed charges,pays at 18% of total charges,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.4,70,,,percent of total billed charges,70% of total billed charges,361.5,75,,,percent of total billed charges,75% of total billed charges,241,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,385.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,482,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,337.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,289.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,337.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,482,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,482,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.53,482,
MAT SUCTION FLOOR,3636438,CDM,272,RC,,,Outpatient,,,40,24,,7.2,18,,,percent of total billed charges,pays at 18% of total charges,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20,50,,,percent of total billed charges,pays at 50% of total billed charges,28,70,,,percent of total billed charges,70% of total billed charges,30,75,,,percent of total billed charges,75% of total billed charges,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,40,
SUCTION FLOOR,3636439,CDM,272,RC,,,Outpatient,,,52.5,31.5,,9.45,18,,,percent of total billed charges,pays at 18% of total charges,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.25,50,,,percent of total billed charges,pays at 50% of total billed charges,36.75,70,,,percent of total billed charges,70% of total billed charges,39.38,75,,,percent of total billed charges,75% of total billed charges,26.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.23,52.5,
SHEARS HARMONIC OPEN,3636440,CDM,272,RC,,,Outpatient,,,677,406.2,,121.86,18,,,percent of total billed charges,pays at 18% of total charges,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,338.5,50,,,percent of total billed charges,pays at 50% of total billed charges,473.9,70,,,percent of total billed charges,70% of total billed charges,507.75,75,,,percent of total billed charges,75% of total billed charges,338.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,541.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,406.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,517.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,473.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,406.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,473.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,677,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,609.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.09,677,
VACURETTE BERKLEY ALL SZ,3636441,CDM,272,RC,,,Outpatient,,,12,7.2,,2.16,18,,,percent of total billed charges,pays at 18% of total charges,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6,50,,,percent of total billed charges,pays at 50% of total billed charges,8.4,70,,,percent of total billed charges,70% of total billed charges,9,75,,,percent of total billed charges,75% of total billed charges,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12,
BINDER PERINEAL,3636442,CDM,272,RC,,,Outpatient,,,17.5,10.5,,3.15,18,,,percent of total billed charges,pays at 18% of total charges,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.75,50,,,percent of total billed charges,pays at 50% of total billed charges,12.25,70,,,percent of total billed charges,70% of total billed charges,13.13,75,,,percent of total billed charges,75% of total billed charges,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.74,17.5,
STOCKING KNEE ANTI EMBOL,3636443,CDM,272,RC,,,Outpatient,,,6,3.6,,1.08,18,,,percent of total billed charges,pays at 18% of total charges,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3,50,,,percent of total billed charges,pays at 50% of total billed charges,4.2,70,,,percent of total billed charges,70% of total billed charges,4.5,75,,,percent of total billed charges,75% of total billed charges,3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.94,6,
STOCKING THIGH ANTI EMBOL,3636444,CDM,271,RC,,,Outpatient,,,11,6.6,,1.98,18,,,percent of total billed charges,pays at 18% of total charges,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.5,50,,,percent of total billed charges,pays at 50% of total billed charges,7.7,70,,,percent of total billed charges,70% of total billed charges,8.25,75,,,percent of total billed charges,75% of total billed charges,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,11,
TEMPLATE BENDING,3636449,CDM,278,RC,C1713,HCPCS,Outpatient,,,76.5,45.9,,13.77,18,,,percent of total billed charges,pays at 18% of total charges,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,70,,,percent of total billed charges,70% of total billed charges,57.38,75,,,percent of total billed charges,75% of total billed charges,38.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,76.5,
TEMPLATE BENDING,3636450,CDM,272,RC,,,Outpatient,,,813.8,488.28,,146.48,18,,,percent of total billed charges,pays at 18% of total charges,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,406.9,50,,,percent of total billed charges,pays at 50% of total billed charges,569.66,70,,,percent of total billed charges,70% of total billed charges,610.35,75,,,percent of total billed charges,75% of total billed charges,406.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,651.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,488.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,622.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,569.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,569.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,813.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,732.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.52,813.8,
ORTHOCORD ALL SZ,3636451,CDM,272,RC,C1713,HCPCS,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
SYRINGE EAR ULCER,3636452,CDM,272,RC,,,Outpatient,,,1.6,0.96,,0.29,18,,,percent of total billed charges,pays at 18% of total charges,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.8,50,,,percent of total billed charges,pays at 50% of total billed charges,1.12,70,,,percent of total billed charges,70% of total billed charges,1.2,75,,,percent of total billed charges,75% of total billed charges,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,1.6,
TRAY SUTURE REMOVAL,3636453,CDM,272,RC,,,Outpatient,,,3.15,1.89,,0.57,18,,,percent of total billed charges,pays at 18% of total charges,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.58,50,,,percent of total billed charges,pays at 50% of total billed charges,2.21,70,,,percent of total billed charges,70% of total billed charges,2.36,75,,,percent of total billed charges,75% of total billed charges,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,3.15,
DEVICE CLOSURE TROCAR,3636456,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
HIP HEMI CAP,3636458,CDM,278,RC,C1776,HCPCS,Outpatient,,,4550,2730,,819,18,,,percent of total billed charges,pays at 18% of total charges,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3185,70,,,percent of total billed charges,70% of total billed charges,3412.5,75,,,percent of total billed charges,75% of total billed charges,2275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4550,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,783.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.99,4550,
AUGMENTATION FEMORAL,3636460,CDM,278,RC,C1776,HCPCS,Outpatient,,,3231.8,1939.08,,581.72,18,,,percent of total billed charges,pays at 18% of total charges,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,581.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2262.26,70,,,percent of total billed charges,70% of total billed charges,2423.85,75,,,percent of total billed charges,75% of total billed charges,1615.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2585.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1939.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,556.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1454.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2262.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1939.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1228.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2262.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1551.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3231.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3231.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.42,3231.8,
SEALANT EVICEL 10ML,3636461,CDM,272,RC,,,Outpatient,,,671,402.6,,120.78,18,,,percent of total billed charges,pays at 18% of total charges,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,335.5,50,,,percent of total billed charges,pays at 50% of total billed charges,469.7,70,,,percent of total billed charges,70% of total billed charges,503.25,75,,,percent of total billed charges,75% of total billed charges,335.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,513.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,469.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,469.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,671,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,603.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.15,671,
SEALANT EVICEL 4ML,3636462,CDM,272,RC,,,Outpatient,,,336.5,201.9,,60.57,18,,,percent of total billed charges,pays at 18% of total charges,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.25,50,,,percent of total billed charges,pays at 50% of total billed charges,235.55,70,,,percent of total billed charges,70% of total billed charges,252.38,75,,,percent of total billed charges,75% of total billed charges,168.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,269.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,235.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,336.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,302.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.73,336.5,
SEALANT COSEAL 4ML,3636463,CDM,272,RC,,,Outpatient,,,828.33,497,,149.1,18,,,percent of total billed charges,pays at 18% of total charges,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,414.17,50,,,percent of total billed charges,pays at 50% of total billed charges,579.83,70,,,percent of total billed charges,70% of total billed charges,621.25,75,,,percent of total billed charges,75% of total billed charges,414.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,662.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,497,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,579.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,497,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,579.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,828.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,745.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.8,828.33,
SYS IMPLANT BICEPS,3636464,CDM,278,RC,C1776,HCPCS,Outpatient,,,1615,969,,290.7,18,,,percent of total billed charges,pays at 18% of total charges,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130.5,70,,,percent of total billed charges,70% of total billed charges,1211.25,75,,,percent of total billed charges,75% of total billed charges,807.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,969,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1615,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,278.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1130.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,969,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,613.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1130.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1615,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1615,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.07,1615,
BUTTON GUIDEPIN,3636465,CDM,272,RC,,,Outpatient,,,277.5,166.5,,49.95,18,,,percent of total billed charges,pays at 18% of total charges,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.75,50,,,percent of total billed charges,pays at 50% of total billed charges,194.25,70,,,percent of total billed charges,70% of total billed charges,208.13,75,,,percent of total billed charges,75% of total billed charges,138.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,249.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.48,277.5,
TIP STRAIGHT POLYMER,3636466,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
PLATE METAGLENE,3636467,CDM,278,RC,C1713,HCPCS,Outpatient,,,2561,1536.6,,460.98,18,,,percent of total billed charges,pays at 18% of total charges,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,460.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1792.7,70,,,percent of total billed charges,70% of total billed charges,1920.75,75,,,percent of total billed charges,75% of total billed charges,1280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2048.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1536.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2561,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,441.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1152.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1792.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1536.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,973.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1792.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1229.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2561,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2561,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.31,2561,
SCREW LCKG ALL SZ,3636468,CDM,278,RC,C1713,HCPCS,Outpatient,,,416,249.6,,74.88,18,,,percent of total billed charges,pays at 18% of total charges,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.2,70,,,percent of total billed charges,70% of total billed charges,312,75,,,percent of total billed charges,75% of total billed charges,208,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,291.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,416,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.19,416,
SCREW NON LCKG ALL SZ,3636469,CDM,278,RC,C1713,HCPCS,Outpatient,,,247,148.2,,44.46,18,,,percent of total billed charges,pays at 18% of total charges,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.9,70,,,percent of total billed charges,70% of total billed charges,185.25,75,,,percent of total billed charges,75% of total billed charges,123.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,197.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,172.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,247,
GLENOSPHERE STD,3636470,CDM,278,RC,C1713,HCPCS,Outpatient,,,3250,1950,,585,18,,,percent of total billed charges,pays at 18% of total charges,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,585,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,70,,,percent of total billed charges,70% of total billed charges,2437.5,75,,,percent of total billed charges,75% of total billed charges,1625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,559.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.28,3250,
ELBOW JOINT,3636471,CDM,278,RC,C1776,HCPCS,Outpatient,,,6515,3909,,1172.7,18,,,percent of total billed charges,pays at 18% of total charges,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1172.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4560.5,70,,,percent of total billed charges,70% of total billed charges,4886.25,75,,,percent of total billed charges,75% of total billed charges,3257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5212,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3909,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6515,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1122.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2931.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4560.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3909,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2475.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4560.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3127.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1020.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.9,6515,
HUMERAL STEM,3636472,CDM,278,RC,C1713,HCPCS,Outpatient,,,3120,1872,,561.6,18,,,percent of total billed charges,pays at 18% of total charges,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,561.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,70,,,percent of total billed charges,70% of total billed charges,2340,75,,,percent of total billed charges,75% of total billed charges,1560,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2496,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1872,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,537.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1872,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1185.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2184,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3120,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3120,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,488.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.9,3120,
HUMERAL CUP,3636473,CDM,278,RC,C1713,HCPCS,Outpatient,,,1989,1193.4,,358.02,18,,,percent of total billed charges,pays at 18% of total charges,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1392.3,70,,,percent of total billed charges,70% of total billed charges,1491.75,75,,,percent of total billed charges,75% of total billed charges,994.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1591.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1193.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1989,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,342.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,895.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1392.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1193.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,755.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1392.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,954.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1989,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1989,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.68,1989,
COMP ARTICULAR SHOULDER,3636474,CDM,278,RC,C1776,HCPCS,Outpatient,,,8050,4830,,1449,18,,,percent of total billed charges,pays at 18% of total charges,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1449,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5635,70,,,percent of total billed charges,70% of total billed charges,6037.5,75,,,percent of total billed charges,75% of total billed charges,4025,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4830,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8050,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1387.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3622.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5635,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4830,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3059,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5635,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8050,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8050,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1261.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.44,8050,
COMP FIXATION SHOULDER,3636475,CDM,278,RC,C1713,HCPCS,Outpatient,,,744,446.4,,133.92,18,,,percent of total billed charges,pays at 18% of total charges,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.8,70,,,percent of total billed charges,70% of total billed charges,558,75,,,percent of total billed charges,75% of total billed charges,372,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,595.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,446.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.58,744,
COMP FIXATION FEMORAL,3636476,CDM,278,RC,C1776,HCPCS,Outpatient,,,1102.4,661.44,,198.43,18,,,percent of total billed charges,pays at 18% of total charges,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.68,70,,,percent of total billed charges,70% of total billed charges,826.8,75,,,percent of total billed charges,75% of total billed charges,551.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,881.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1102.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1102.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1102.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.75,1102.4,
SYSTEM ELBOW STABILIZATION,3636477,CDM,278,RC,C1776,HCPCS,Outpatient,,,7059,4235.4,,1270.62,18,,,percent of total billed charges,pays at 18% of total charges,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1270.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4941.3,70,,,percent of total billed charges,70% of total billed charges,5294.25,75,,,percent of total billed charges,75% of total billed charges,3529.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5647.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4235.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7059,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1216.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3176.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4941.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4235.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2682.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4941.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3388.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7059,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7059,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1106.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1106.15,7059,
COMP ARTICULAR MTP,3636478,CDM,278,RC,C1713,HCPCS,Outpatient,,,2600,1560,,468,18,,,percent of total billed charges,pays at 18% of total charges,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,70,,,percent of total billed charges,70% of total billed charges,1950,75,,,percent of total billed charges,75% of total billed charges,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,447.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,988,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.42,2600,
COMPONENT FIXATION,3636479,CDM,272,RC,,,Outpatient,,,514,308.4,,92.52,18,,,percent of total billed charges,pays at 18% of total charges,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257,50,,,percent of total billed charges,pays at 50% of total billed charges,359.8,70,,,percent of total billed charges,70% of total billed charges,385.5,75,,,percent of total billed charges,75% of total billed charges,257,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,411.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,359.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,359.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,514,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,462.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.54,514,
COMP ARTICULAR FEMORAL,3636480,CDM,278,RC,C1776,HCPCS,Outpatient,,,7208.5,4325.1,,1297.53,18,,,percent of total billed charges,pays at 18% of total charges,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1297.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5045.95,70,,,percent of total billed charges,70% of total billed charges,5406.38,75,,,percent of total billed charges,75% of total billed charges,3604.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5766.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4325.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7208.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1242.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3243.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5045.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4325.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2739.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5045.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3460.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7208.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7208.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1129.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1129.57,7208.5,
COMP ARTICULAR PATELLA,3636481,CDM,278,RC,C1776,HCPCS,Outpatient,,,895,537,,161.1,18,,,percent of total billed charges,pays at 18% of total charges,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.5,70,,,percent of total billed charges,70% of total billed charges,671.25,75,,,percent of total billed charges,75% of total billed charges,447.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,716,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,537,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,895,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,626.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,537,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,626.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.25,895,
COMP ART PATELLA BUTTON,3636482,CDM,278,RC,C1776,HCPCS,Outpatient,,,895,537,,161.1,18,,,percent of total billed charges,pays at 18% of total charges,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.5,70,,,percent of total billed charges,70% of total billed charges,671.25,75,,,percent of total billed charges,75% of total billed charges,447.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,716,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,537,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,895,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,626.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,537,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,626.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.25,895,
COMP FIXATION PATELLA,3636483,CDM,278,RC,C1713,HCPCS,Outpatient,,,744,446.4,,133.92,18,,,percent of total billed charges,pays at 18% of total charges,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.8,70,,,percent of total billed charges,70% of total billed charges,558,75,,,percent of total billed charges,75% of total billed charges,372,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,595.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,744,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,446.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,520.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.58,744,
COMP ART FEMORAL UNI,3636484,CDM,278,RC,C1776,HCPCS,Outpatient,,,6737,4042.2,,1212.66,18,,,percent of total billed charges,pays at 18% of total charges,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1212.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4715.9,70,,,percent of total billed charges,70% of total billed charges,5052.75,75,,,percent of total billed charges,75% of total billed charges,3368.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5389.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4042.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6737,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1160.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3031.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4715.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4042.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2560.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4715.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3233.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6737,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6737,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1055.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1055.69,6737,
COMP FIXATION FEMORAL UNI,3636485,CDM,278,RC,C1776,HCPCS,Outpatient,,,802.5,481.5,,144.45,18,,,percent of total billed charges,pays at 18% of total charges,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.75,70,,,percent of total billed charges,70% of total billed charges,601.88,75,,,percent of total billed charges,75% of total billed charges,401.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,642,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,561.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,481.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,561.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,802.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,802.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.75,802.5,
COMP ARTICULAR TIBIAL UNI,3636486,CDM,278,RC,C1776,HCPCS,Outpatient,,,850,510,,153,18,,,percent of total billed charges,pays at 18% of total charges,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595,70,,,percent of total billed charges,70% of total billed charges,637.5,75,,,percent of total billed charges,75% of total billed charges,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,595,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,595,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,850,
CUTTER TIBIAL,3636487,CDM,272,RC,,,Outpatient,,,454,272.4,,81.72,18,,,percent of total billed charges,pays at 18% of total charges,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227,50,,,percent of total billed charges,pays at 50% of total billed charges,317.8,70,,,percent of total billed charges,70% of total billed charges,340.5,75,,,percent of total billed charges,75% of total billed charges,227,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,363.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,347.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,317.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,272.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,317.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,454,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,408.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.14,454,
CARTRIDGE CEMENT,3636488,CDM,272,RC,,,Outpatient,,,134,80.4,,24.12,18,,,percent of total billed charges,pays at 18% of total charges,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67,50,,,percent of total billed charges,pays at 50% of total billed charges,93.8,70,,,percent of total billed charges,70% of total billed charges,100.5,75,,,percent of total billed charges,75% of total billed charges,67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,134,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,134,
INTEGRA WOUND MATRIX PER  SQ CM,3636489,CDM,636,RC,Q4104,HCPCS,Outpatient,,,40,24,,7.2,18,,,percent of total billed charges,pays at 18% of total charges,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20,50,,,percent of total billed charges,pays at 50% of total billed charges,28,70,,,percent of total billed charges,70% of total billed charges,30,75,,,percent of total billed charges,75% of total billed charges,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,40,
CINCH MENISCAL,3636490,CDM,278,RC,C1713,HCPCS,Outpatient,,,530,318,,95.4,18,,,percent of total billed charges,pays at 18% of total charges,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371,70,,,percent of total billed charges,70% of total billed charges,397.5,75,,,percent of total billed charges,75% of total billed charges,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,91.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,371,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,530,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,530,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.05,530,
MATERIAL BONE HEMOSTASIS,3636492,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
ASSY CLAVICLE PIN,3636493,CDM,278,RC,C1776,HCPCS,Outpatient,,,1612,967.2,,290.16,18,,,percent of total billed charges,pays at 18% of total charges,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.4,70,,,percent of total billed charges,70% of total billed charges,1209,75,,,percent of total billed charges,75% of total billed charges,806,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,967.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,277.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1128.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,967.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,612.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1128.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1612,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1612,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.6,1612,
NEEDLE NERVE BLOCK,3636495,CDM,272,RC,,,Outpatient,,,30,18,,5.4,18,,,percent of total billed charges,pays at 18% of total charges,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15,50,,,percent of total billed charges,pays at 50% of total billed charges,21,70,,,percent of total billed charges,70% of total billed charges,22.5,75,,,percent of total billed charges,75% of total billed charges,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,30,
MATRIX WOUND 3LAYER PER SQ CM,3636496,CDM,636,RC,Q4166,HCPCS,Outpatient,,,34.44,20.66,,6.2,18,,,percent of total billed charges,pays at 18% of total charges,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.22,50,,,percent of total billed charges,pays at 50% of total billed charges,24.11,70,,,percent of total billed charges,70% of total billed charges,25.83,75,,,percent of total billed charges,75% of total billed charges,17.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,27.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,34.44,
STETHOSCOPE ESOPHAGEAL,3636497,CDM,272,RC,,,Outpatient,,,5.75,3.45,,1.04,18,,,percent of total billed charges,pays at 18% of total charges,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.88,50,,,percent of total billed charges,pays at 50% of total billed charges,4.03,70,,,percent of total billed charges,70% of total billed charges,4.31,75,,,percent of total billed charges,75% of total billed charges,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,5.75,
MASK LARYNGEAL ALL SZ,3636498,CDM,272,RC,,,Outpatient,,,32,19.2,,5.76,18,,,percent of total billed charges,pays at 18% of total charges,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16,50,,,percent of total billed charges,pays at 50% of total billed charges,22.4,70,,,percent of total billed charges,70% of total billed charges,24,75,,,percent of total billed charges,75% of total billed charges,16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.01,32,
ACETABULAR RESTRICTOR,3636499,CDM,272,RC,,,Outpatient,,,1608,964.8,,289.44,18,,,percent of total billed charges,pays at 18% of total charges,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,289.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,804,50,,,percent of total billed charges,pays at 50% of total billed charges,1125.6,70,,,percent of total billed charges,70% of total billed charges,1206,75,,,percent of total billed charges,75% of total billed charges,804,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1286.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,964.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1230.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,964.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,611.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1608,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1447.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.97,1608,
LMA FASTRACH ALL SZ,3636500,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
IMPLANT ENDOTINE RIBBON,3636501,CDM,278,RC,,,Outpatient,,,643.5,386.1,,115.83,18,,,percent of total billed charges,pays at 18% of total charges,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.75,50,,,percent of total billed charges,pays at 50% of total billed charges,450.45,70,,,percent of total billed charges,70% of total billed charges,482.63,75,,,percent of total billed charges,75% of total billed charges,321.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,643.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,643.5,
IMPLANT ENDOTINE FOREHEAD,3636502,CDM,278,RC,,,Outpatient,,,300,180,,54,18,,,percent of total billed charges,pays at 18% of total charges,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,50,,,percent of total billed charges,pays at 50% of total billed charges,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.01,300,
PAC HIP,3636503,CDM,272,RC,,,Outpatient,,,546,327.6,,98.28,18,,,percent of total billed charges,pays at 18% of total charges,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,273,50,,,percent of total billed charges,pays at 50% of total billed charges,382.2,70,,,percent of total billed charges,70% of total billed charges,409.5,75,,,percent of total billed charges,75% of total billed charges,273,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,436.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,417.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,382.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,327.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,382.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,546,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,491.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.56,546,
PAD FOOT,3636504,CDM,272,RC,,,Outpatient,,,200,120,,36,18,,,percent of total billed charges,pays at 18% of total charges,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100,50,,,percent of total billed charges,pays at 50% of total billed charges,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,200,
PAD PERONEAL,3636505,CDM,272,RC,,,Outpatient,,,103,61.8,,18.54,18,,,percent of total billed charges,pays at 18% of total charges,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.5,50,,,percent of total billed charges,pays at 50% of total billed charges,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,51.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,103,
DRESSING PRIMAPORE ALL SZ,3636506,CDM,272,RC,,,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
SUCTION INFLOW OUTFLOW,3636507,CDM,272,RC,,,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,50,,,percent of total billed charges,pays at 50% of total billed charges,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,125,
ADAPTER LUER TO COLDER,3636508,CDM,272,RC,,,Outpatient,,,11,6.6,,1.98,18,,,percent of total billed charges,pays at 18% of total charges,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.5,50,,,percent of total billed charges,pays at 50% of total billed charges,7.7,70,,,percent of total billed charges,70% of total billed charges,8.25,75,,,percent of total billed charges,75% of total billed charges,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,11,
LEADS CARDIAC DISP,3636509,CDM,270,RC,,,Outpatient,,,42.5,25.5,,7.65,18,,,percent of total billed charges,pays at 18% of total charges,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.25,50,,,percent of total billed charges,pays at 50% of total billed charges,29.75,70,,,percent of total billed charges,70% of total billed charges,31.88,75,,,percent of total billed charges,75% of total billed charges,21.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,42.5,
KNEE UNI MED LAT,3636510,CDM,278,RC,C1776,HCPCS,Outpatient,,,8275,4965,,1489.5,18,,,percent of total billed charges,pays at 18% of total charges,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1489.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5792.5,70,,,percent of total billed charges,70% of total billed charges,6206.25,75,,,percent of total billed charges,75% of total billed charges,4137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4965,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8275,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1425.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3723.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5792.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4965,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3144.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5792.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3972,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1296.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.69,8275,
PATELLA UNI,3636511,CDM,278,RC,C1776,HCPCS,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
SCREW PEG,3636512,CDM,278,RC,C1713,HCPCS,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
PEG SMOOTH,3636513,CDM,278,RC,C1713,HCPCS,Outpatient,,,201,120.6,,36.18,18,,,percent of total billed charges,pays at 18% of total charges,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,70,,,percent of total billed charges,70% of total billed charges,150.75,75,,,percent of total billed charges,75% of total billed charges,100.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,201,
AUGMENTATION FEMORAL,3636514,CDM,278,RC,C1776,HCPCS,Outpatient,,,1125,675,,202.5,18,,,percent of total billed charges,pays at 18% of total charges,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.5,70,,,percent of total billed charges,70% of total billed charges,843.75,75,,,percent of total billed charges,75% of total billed charges,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1125,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,787.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,675,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,787.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.29,1125,
AUGMENTATION FEM,3636515,CDM,278,RC,C1776,HCPCS,Outpatient,,,1086,651.6,,195.48,18,,,percent of total billed charges,pays at 18% of total charges,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.2,70,,,percent of total billed charges,70% of total billed charges,814.5,75,,,percent of total billed charges,75% of total billed charges,543,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,868.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,651.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1086,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,760.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,651.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,760.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1086,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1086,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.18,1086,
TIBIAL FLUTED ROD,3636516,CDM,278,RC,C1776,HCPCS,Outpatient,,,1399,839.4,,251.82,18,,,percent of total billed charges,pays at 18% of total charges,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.3,70,,,percent of total billed charges,70% of total billed charges,1049.25,75,,,percent of total billed charges,75% of total billed charges,699.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,839.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1399,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,241.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,979.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,839.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,531.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,979.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,671.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1399,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1399,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.22,1399,
FEMORAL FLUTED ROD,3636517,CDM,278,RC,C1776,HCPCS,Outpatient,,,1721,1032.6,,309.78,18,,,percent of total billed charges,pays at 18% of total charges,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,309.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1204.7,70,,,percent of total billed charges,70% of total billed charges,1290.75,75,,,percent of total billed charges,75% of total billed charges,860.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1032.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1721,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,296.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1204.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1032.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,653.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1204.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,826.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1721,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1721,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.68,1721,
STEM PLUG,3636518,CDM,278,RC,C1776,HCPCS,Outpatient,,,1108,664.8,,199.44,18,,,percent of total billed charges,pays at 18% of total charges,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.6,70,,,percent of total billed charges,70% of total billed charges,831,75,,,percent of total billed charges,75% of total billed charges,554,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,886.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,664.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1108,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,190.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,775.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,664.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,421.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,775.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,531.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.62,1108,
SCREW ANTI ROTATION,3636519,CDM,278,RC,C1713,HCPCS,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
CAP LCKG PANGRA,3636520,CDM,278,RC,C1713,HCPCS,Outpatient,,,501.8,301.08,,90.32,18,,,percent of total billed charges,pays at 18% of total charges,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.26,70,,,percent of total billed charges,70% of total billed charges,376.35,75,,,percent of total billed charges,75% of total billed charges,250.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,401.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,301.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,501.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,351.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,501.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,501.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.63,501.8,
SCREW POLYAXIAL,3636521,CDM,278,RC,C1713,HCPCS,Outpatient,,,1693.9,1016.34,,304.9,18,,,percent of total billed charges,pays at 18% of total charges,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,304.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1185.73,70,,,percent of total billed charges,70% of total billed charges,1270.43,75,,,percent of total billed charges,75% of total billed charges,846.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1355.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1016.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1693.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,291.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1185.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1016.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,643.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1185.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,813.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1693.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1693.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,265.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.43,1693.9,
SCREW PEDICLE,3636522,CDM,278,RC,C1713,HCPCS,Outpatient,,,1606.51,963.91,,289.17,18,,,percent of total billed charges,pays at 18% of total charges,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,289.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.56,70,,,percent of total billed charges,70% of total billed charges,1204.88,75,,,percent of total billed charges,75% of total billed charges,803.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1285.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,963.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1606.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,276.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1124.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,963.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,610.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1124.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1606.51,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1606.51,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.74,1606.51,
DRILL BIT ANCHOR PEG,3636523,CDM,272,RC,,,Outpatient,,,285,171,,51.3,18,,,percent of total billed charges,pays at 18% of total charges,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,50,,,percent of total billed charges,pays at 50% of total billed charges,199.5,70,,,percent of total billed charges,70% of total billed charges,213.75,75,,,percent of total billed charges,75% of total billed charges,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,285,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,285,
STAND IMPACTION,3636524,CDM,272,RC,,,Outpatient,,,520,312,,93.6,18,,,percent of total billed charges,pays at 18% of total charges,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260,50,,,percent of total billed charges,pays at 50% of total billed charges,364,70,,,percent of total billed charges,70% of total billed charges,390,75,,,percent of total billed charges,75% of total billed charges,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,468,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,520,
KIT ANESTHESIA ADULT,3636525,CDM,272,RC,,,Outpatient,,,70,42,,12.6,18,,,percent of total billed charges,pays at 18% of total charges,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,70,
KIT ANESTHESIA HEART,3636526,CDM,272,RC,,,Outpatient,,,306.33,183.8,,55.14,18,,,percent of total billed charges,pays at 18% of total charges,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.17,50,,,percent of total billed charges,pays at 50% of total billed charges,214.43,70,,,percent of total billed charges,70% of total billed charges,229.75,75,,,percent of total billed charges,75% of total billed charges,153.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,306.33,
COUNTERSINK,3636527,CDM,272,RC,,,Outpatient,,,191.5,114.9,,34.47,18,,,percent of total billed charges,pays at 18% of total charges,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.75,50,,,percent of total billed charges,pays at 50% of total billed charges,134.05,70,,,percent of total billed charges,70% of total billed charges,143.63,75,,,percent of total billed charges,75% of total billed charges,95.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,191.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,172.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.01,191.5,
VEIN HUMAN,3636528,CDM,278,RC,C1762,HCPCS,Outpatient,,,10400,6240,,1872,18,,,percent of total billed charges,pays at 18% of total charges,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1872,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7280,70,,,percent of total billed charges,70% of total billed charges,7800,75,,,percent of total billed charges,75% of total billed charges,5200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10400,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1791.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4680,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3952,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4992,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1629.68,10400,
CANNULA WITH SCOPE,3636529,CDM,272,RC,,,Outpatient,,,1260,756,,226.8,18,,,percent of total billed charges,pays at 18% of total charges,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630,50,,,percent of total billed charges,pays at 50% of total billed charges,882,70,,,percent of total billed charges,70% of total billed charges,945,75,,,percent of total billed charges,75% of total billed charges,630,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,756,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,963.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,478.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1260,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1134,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.44,1260,
KIT ORTHO PROCEDURAL,3636530,CDM,272,RC,,,Outpatient,,,132,79.2,,23.76,18,,,percent of total billed charges,pays at 18% of total charges,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66,50,,,percent of total billed charges,pays at 50% of total billed charges,92.4,70,,,percent of total billed charges,70% of total billed charges,99,75,,,percent of total billed charges,75% of total billed charges,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,132,
SEALANT INTEGUSEAL MICROB,3636531,CDM,272,RC,,,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
SET ACP DOUBLE SYRINGE,3636532,CDM,272,RC,,,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.5,50,,,percent of total billed charges,pays at 50% of total billed charges,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
PEN TRANSPOLAR ABLATION,3636533,CDM,272,RC,,,Outpatient,,,3315,1989,,596.7,18,,,percent of total billed charges,pays at 18% of total charges,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1657.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2320.5,70,,,percent of total billed charges,70% of total billed charges,2486.25,75,,,percent of total billed charges,75% of total billed charges,1657.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1989,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2535.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1491.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2320.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1989,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1259.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2320.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1591.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2983.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.46,3315,
CLAMP LONG JAW ABLATION,3636534,CDM,272,RC,,,Outpatient,,,5103,3061.8,,918.54,18,,,percent of total billed charges,pays at 18% of total charges,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,918.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2551.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3572.1,70,,,percent of total billed charges,70% of total billed charges,3827.25,75,,,percent of total billed charges,75% of total billed charges,2551.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4082.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3061.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3903.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2296.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3572.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3061.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1939.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3572.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2449.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5103,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4592.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,799.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.64,5103,
STEM EXTENSION,3636535,CDM,278,RC,C1776,HCPCS,Outpatient,,,5860.5,3516.3,,1054.89,18,,,percent of total billed charges,pays at 18% of total charges,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1054.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4102.35,70,,,percent of total billed charges,70% of total billed charges,4395.38,75,,,percent of total billed charges,75% of total billed charges,2930.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4688.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3516.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5860.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1009.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2637.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4102.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3516.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2226.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4102.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2813.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5860.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5860.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,918.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,918.34,5860.5,
HUMERAL SOCKET INSERT,3636536,CDM,278,RC,C1776,HCPCS,Outpatient,,,1404,842.4,,252.72,18,,,percent of total billed charges,pays at 18% of total charges,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.8,70,,,percent of total billed charges,70% of total billed charges,1053,75,,,percent of total billed charges,75% of total billed charges,702,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,842.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1404,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,241.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,982.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,842.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,982.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.01,1404,
HUMERAL SOCKET SHELL,3636537,CDM,278,RC,C1776,HCPCS,Outpatient,,,2720.25,1632.15,,489.65,18,,,percent of total billed charges,pays at 18% of total charges,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1904.18,70,,,percent of total billed charges,70% of total billed charges,2040.19,75,,,percent of total billed charges,75% of total billed charges,1360.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2176.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1632.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2720.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,468.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1224.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1904.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1632.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1033.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1904.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1305.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2720.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2720.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.26,2720.25,
KIT HIP CORE DEC CA SULF,3636538,CDM,278,RC,C1713,HCPCS,Outpatient,,,77,46.2,,13.86,18,,,percent of total billed charges,pays at 18% of total charges,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.9,70,,,percent of total billed charges,70% of total billed charges,57.75,75,,,percent of total billed charges,75% of total billed charges,38.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.07,77,
BLADE XBEAM,3636539,CDM,272,RC,,,Outpatient,,,700,420,,126,18,,,percent of total billed charges,pays at 18% of total charges,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,350,50,,,percent of total billed charges,pays at 50% of total billed charges,490,70,,,percent of total billed charges,70% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,535.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,630,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.69,700,
CAGE SPINAL,3636540,CDM,278,RC,,,Outpatient,,,6850,4110,,1233,18,,,percent of total billed charges,pays at 18% of total charges,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1233,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3425,50,,,percent of total billed charges,pays at 50% of total billed charges,4795,70,,,percent of total billed charges,70% of total billed charges,5137.5,75,,,percent of total billed charges,75% of total billed charges,3425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4110,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3082.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4795,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4110,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2603,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4795,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3288,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1073.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1073.4,6850,
KIT CENTRIFUGE SPIN,3636541,CDM,272,RC,,,Outpatient,,,40,24,,7.2,18,,,percent of total billed charges,pays at 18% of total charges,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20,50,,,percent of total billed charges,pays at 50% of total billed charges,28,70,,,percent of total billed charges,70% of total billed charges,30,75,,,percent of total billed charges,75% of total billed charges,20,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,40,
KIT SPRAY,3636542,CDM,272,RC,,,Outpatient,,,70,42,,12.6,18,,,percent of total billed charges,pays at 18% of total charges,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,70,
TIP SPRAY,3636543,CDM,272,RC,,,Outpatient,,,64,38.4,,11.52,18,,,percent of total billed charges,pays at 18% of total charges,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32,50,,,percent of total billed charges,pays at 50% of total billed charges,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,64,
KIT PLATELET CONC SEP GPS,3636544,CDM,272,RC,,,Outpatient,,,522,313.2,,93.96,18,,,percent of total billed charges,pays at 18% of total charges,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261,50,,,percent of total billed charges,pays at 50% of total billed charges,365.4,70,,,percent of total billed charges,70% of total billed charges,391.5,75,,,percent of total billed charges,75% of total billed charges,261,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,417.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,313.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,399.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,365.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,522,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,469.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.8,522,
KIT MCCONNELL ARM,3636545,CDM,272,RC,,,Outpatient,,,70,42,,12.6,18,,,percent of total billed charges,pays at 18% of total charges,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,70,
HUMERAL NECK NEUTRAL,3636546,CDM,278,RC,C1776,HCPCS,Outpatient,,,2184,1310.4,,393.12,18,,,percent of total billed charges,pays at 18% of total charges,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,393.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1528.8,70,,,percent of total billed charges,70% of total billed charges,1638,75,,,percent of total billed charges,75% of total billed charges,1092,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1747.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1310.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2184,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1528.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1310.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,829.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1528.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1048.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.23,2184,
DEVICE XTENDOBUTTON FIX,3636547,CDM,278,RC,C1713,HCPCS,Outpatient,,,243,145.8,,43.74,18,,,percent of total billed charges,pays at 18% of total charges,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,70,,,percent of total billed charges,70% of total billed charges,182.25,75,,,percent of total billed charges,75% of total billed charges,121.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,194.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,170.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,170.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,243,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.08,243,
CORKSCREW SUBDERMAL,3636548,CDM,272,RC,,,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.5,50,,,percent of total billed charges,pays at 50% of total billed charges,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,75,
ELECTRODE SURFACE PREGEL,3636549,CDM,272,RC,,,Outpatient,,,811,486.6,,145.98,18,,,percent of total billed charges,pays at 18% of total charges,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405.5,50,,,percent of total billed charges,pays at 50% of total billed charges,567.7,70,,,percent of total billed charges,70% of total billed charges,608.25,75,,,percent of total billed charges,75% of total billed charges,405.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,648.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,486.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,620.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,567.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,486.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,567.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,811,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,729.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.08,811,
ELECTRODE SUBDERMAL NDL,3636550,CDM,272,RC,,,Outpatient,,,437,262.2,,78.66,18,,,percent of total billed charges,pays at 18% of total charges,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.5,50,,,percent of total billed charges,pays at 50% of total billed charges,305.9,70,,,percent of total billed charges,70% of total billed charges,327.75,75,,,percent of total billed charges,75% of total billed charges,218.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,305.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,305.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,437,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,393.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.48,437,
ASSY ULTRA FIX DELIVERY,3636551,CDM,278,RC,,,Outpatient,,,448,268.8,,80.64,18,,,percent of total billed charges,pays at 18% of total charges,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224,50,,,percent of total billed charges,pays at 50% of total billed charges,313.6,70,,,percent of total billed charges,70% of total billed charges,336,75,,,percent of total billed charges,75% of total billed charges,224,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,448,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.2,448,
ASSY FAST FIX AB,3636552,CDM,278,RC,,,Outpatient,,,437,262.2,,78.66,18,,,percent of total billed charges,pays at 18% of total charges,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.5,50,,,percent of total billed charges,pays at 50% of total billed charges,305.9,70,,,percent of total billed charges,70% of total billed charges,327.75,75,,,percent of total billed charges,75% of total billed charges,218.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,349.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,437,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,305.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,305.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,437,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,437,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.48,437,
COLLAGEN WRAP NERVE PER 0.5 CM,3636553,CDM,278,RC,C9361,HCPCS,Outpatient,,,410,246,,73.8,18,,,percent of total billed charges,pays at 18% of total charges,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,50,,,percent of total billed charges,pays at 50% of total billed charges,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
COLLAGEN WRAP NERVE PER 0.5 CM,3636554,CDM,278,RC,C9361,HCPCS,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
MATRIX WD DERMACELL PER SQ CM,3636555,CDM,636,RC,Q4122,HCPCS,Outpatient,,,117,70.2,,21.06,18,,,percent of total billed charges,pays at 18% of total charges,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,50,,,percent of total billed charges,pays at 50% of total billed charges,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,117,
HUMERAL STEM PRIMARY,3636558,CDM,278,RC,C1776,HCPCS,Outpatient,,,5009,3005.4,,901.62,18,,,percent of total billed charges,pays at 18% of total charges,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,901.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3506.3,70,,,percent of total billed charges,70% of total billed charges,3756.75,75,,,percent of total billed charges,75% of total billed charges,2504.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4007.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3005.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5009,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,863.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2254.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3506.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3005.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1903.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3506.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2404.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5009,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5009,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,784.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.91,5009,
SPEARS SURGICAL,3636559,CDM,272,RC,,,Outpatient,,,70,42,,12.6,18,,,percent of total billed charges,pays at 18% of total charges,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,70,
MATERIAL BACKGROUND MICRO,3636560,CDM,272,RC,,,Outpatient,,,158,94.8,,28.44,18,,,percent of total billed charges,pays at 18% of total charges,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79,50,,,percent of total billed charges,pays at 50% of total billed charges,110.6,70,,,percent of total billed charges,70% of total billed charges,118.5,75,,,percent of total billed charges,75% of total billed charges,79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.76,158,
TOOL CRUCIAL SMOOTHER,3636561,CDM,272,RC,,,Outpatient,,,400,240,,72,18,,,percent of total billed charges,pays at 18% of total charges,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200,50,,,percent of total billed charges,pays at 50% of total billed charges,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.68,400,
GRAFT STRT PTFE,3636562,CDM,278,RC,C1768,HCPCS,Outpatient,,,3482,2089.2,,626.76,18,,,percent of total billed charges,pays at 18% of total charges,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,626.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2437.4,70,,,percent of total billed charges,70% of total billed charges,2611.5,75,,,percent of total billed charges,75% of total billed charges,1741,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2785.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2089.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3482,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,599.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1566.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2437.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2089.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1323.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2437.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1671.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3482,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3482,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,545.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.63,3482,
SUTURE STRATAFIX,3636563,CDM,272,RC,,,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.5,50,,,percent of total billed charges,pays at 50% of total billed charges,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,75,
TROCAR HASSON 12MM,3636564,CDM,272,RC,,,Outpatient,,,90,54,,16.2,18,,,percent of total billed charges,pays at 18% of total charges,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,50,,,percent of total billed charges,pays at 50% of total billed charges,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,90,
GRASPER 5MM X 38MM,3636565,CDM,272,RC,,,Outpatient,,,110,66,,19.8,18,,,percent of total billed charges,pays at 18% of total charges,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55,50,,,percent of total billed charges,pays at 50% of total billed charges,77,70,,,percent of total billed charges,70% of total billed charges,82.5,75,,,percent of total billed charges,75% of total billed charges,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,110,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.24,110,
OBTURATOR DISP,3636566,CDM,272,RC,,,Outpatient,,,268.5,161.1,,48.33,18,,,percent of total billed charges,pays at 18% of total charges,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.25,50,,,percent of total billed charges,pays at 50% of total billed charges,187.95,70,,,percent of total billed charges,70% of total billed charges,201.38,75,,,percent of total billed charges,75% of total billed charges,134.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,187.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,187.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.07,268.5,
PIN PULL,3636568,CDM,272,RC,,,Outpatient,,,172.5,103.5,,31.05,18,,,percent of total billed charges,pays at 18% of total charges,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.25,50,,,percent of total billed charges,pays at 50% of total billed charges,120.75,70,,,percent of total billed charges,70% of total billed charges,129.38,75,,,percent of total billed charges,75% of total billed charges,86.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,120.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,172.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.03,172.5,
MORCELLATOR,3636569,CDM,272,RC,,,Outpatient,,,1040,624,,187.2,18,,,percent of total billed charges,pays at 18% of total charges,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520,50,,,percent of total billed charges,pays at 50% of total billed charges,728,70,,,percent of total billed charges,70% of total billed charges,780,75,,,percent of total billed charges,75% of total billed charges,520,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,832,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,795.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,624,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,728,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1040,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,936,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.97,1040,
SLEEVE GLIDESCOPE,3636570,CDM,272,RC,,,Outpatient,,,78,46.8,,14.04,18,,,percent of total billed charges,pays at 18% of total charges,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39,50,,,percent of total billed charges,pays at 50% of total billed charges,54.6,70,,,percent of total billed charges,70% of total billed charges,58.5,75,,,percent of total billed charges,75% of total billed charges,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.22,78,
ENDOTUBE FASTRACH,3636571,CDM,272,RC,,,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.5,50,,,percent of total billed charges,pays at 50% of total billed charges,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,75,
BLADE EXPLANT SYSTEM,3636575,CDM,272,RC,,,Outpatient,,,1400,840,,252,18,,,percent of total billed charges,pays at 18% of total charges,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,700,50,,,percent of total billed charges,pays at 50% of total billed charges,980,70,,,percent of total billed charges,70% of total billed charges,1050,75,,,percent of total billed charges,75% of total billed charges,700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1071,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,980,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,532,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,980,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1260,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.38,1400,
PIN PREFIX,3636576,CDM,272,RC,,,Outpatient,,,283.5,170.1,,51.03,18,,,percent of total billed charges,pays at 18% of total charges,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.75,50,,,percent of total billed charges,pays at 50% of total billed charges,198.45,70,,,percent of total billed charges,70% of total billed charges,212.63,75,,,percent of total billed charges,75% of total billed charges,141.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,255.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,283.5,
SYSTEM CPAP,3636579,CDM,272,RC,,,Outpatient,,,52,31.2,,9.36,18,,,percent of total billed charges,pays at 18% of total charges,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26,50,,,percent of total billed charges,pays at 50% of total billed charges,36.4,70,,,percent of total billed charges,70% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,52,
SYS FIBULA ROD,3636580,CDM,278,RC,C1713,HCPCS,Outpatient,,,1548.5,929.1,,278.73,18,,,percent of total billed charges,pays at 18% of total charges,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,278.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1083.95,70,,,percent of total billed charges,70% of total billed charges,1161.38,75,,,percent of total billed charges,75% of total billed charges,774.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1238.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,929.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1548.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,266.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1083.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,929.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,588.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1083.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1548.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1548.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.65,1548.5,
DRESSING AG STERILE,3636583,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
STENT ESOPHAGEAL,3636584,CDM,278,RC,C2625,HCPCS,Outpatient,,,2613,1567.8,,470.34,18,,,percent of total billed charges,pays at 18% of total charges,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1829.1,70,,,percent of total billed charges,70% of total billed charges,1959.75,75,,,percent of total billed charges,75% of total billed charges,1306.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1567.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2613,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,450.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1829.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1567.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1829.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2613,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2613,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.46,2613,
ROD HUNTER TENDON,3636585,CDM,278,RC,C1713,HCPCS,Outpatient,,,2442,1465.2,,439.56,18,,,percent of total billed charges,pays at 18% of total charges,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.4,70,,,percent of total billed charges,70% of total billed charges,1831.5,75,,,percent of total billed charges,75% of total billed charges,1221,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1953.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1465.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2442,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,420.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1709.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1465.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,927.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1709.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2442,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2442,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.66,2442,
SYS LAA EXCURSION,3636586,CDM,272,RC,,,Outpatient,,,1600,960,,288,18,,,percent of total billed charges,pays at 18% of total charges,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,800,50,,,percent of total billed charges,pays at 50% of total billed charges,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,608,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.72,1600,
PLUG FISTULA,3636587,CDM,278,RC,C1781,HCPCS,Outpatient,,,1075,645,,193.5,18,,,percent of total billed charges,pays at 18% of total charges,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.5,70,,,percent of total billed charges,70% of total billed charges,806.25,75,,,percent of total billed charges,75% of total billed charges,537.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1075,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,185.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,752.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,752.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1075,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1075,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.45,1075,
SPACER CMC BONE,3636593,CDM,278,RC,L8658,HCPCS,Outpatient,,,2900,1740,,522,18,,,percent of total billed charges,pays at 18% of total charges,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,522,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1450,50,,,percent of total billed charges,pays at 50% of total billed charges,2030,70,,,percent of total billed charges,70% of total billed charges,2175,75,,,percent of total billed charges,75% of total billed charges,1450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1740,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,499.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1305,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2030,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1740,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1102,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2030,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1392,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.43,2900,
INFUSE BONE GRAFT XSM,3636594,CDM,278,RC,C1762,HCPCS,Outpatient,,,2325,1395,,418.5,18,,,percent of total billed charges,pays at 18% of total charges,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.5,70,,,percent of total billed charges,70% of total billed charges,1743.75,75,,,percent of total billed charges,75% of total billed charges,1162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1395,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2325,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,400.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1627.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1395,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,883.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1627.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.33,2325,
RETRIEVER SUTURE HEWSON,3636595,CDM,272,RC,,,Outpatient,,,750,450,,135,18,,,percent of total billed charges,pays at 18% of total charges,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,375,50,,,percent of total billed charges,pays at 50% of total billed charges,525,70,,,percent of total billed charges,70% of total billed charges,562.5,75,,,percent of total billed charges,75% of total billed charges,375,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,573.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,525,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,450,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,525,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,675,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.53,750,
IMPLANT MENISCAL TISSUE,3636596,CDM,278,RC,C1762,HCPCS,Outpatient,,,6175,3705,,1111.5,18,,,percent of total billed charges,pays at 18% of total charges,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4322.5,70,,,percent of total billed charges,70% of total billed charges,4631.25,75,,,percent of total billed charges,75% of total billed charges,3087.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4940,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3705,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6175,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1063.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2778.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4322.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3705,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2346.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4322.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2964,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6175,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6175,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.62,6175,
SHIM FEMORAL DISP,3636597,CDM,272,RC,,,Outpatient,,,1307,784.2,,235.26,18,,,percent of total billed charges,pays at 18% of total charges,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,653.5,50,,,percent of total billed charges,pays at 50% of total billed charges,914.9,70,,,percent of total billed charges,70% of total billed charges,980.25,75,,,percent of total billed charges,75% of total billed charges,653.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1045.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,999.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,914.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,784.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,496.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,914.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1307,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1176.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.81,1307,
TRAY TRACHEOTOMY DISP,3636598,CDM,272,RC,,,Outpatient,,,147,88.2,,26.46,18,,,percent of total billed charges,pays at 18% of total charges,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.5,50,,,percent of total billed charges,pays at 50% of total billed charges,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,73.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,147,
TRAY LACERATION DISP,3636599,CDM,272,RC,,,Outpatient,,,20,12,,3.6,18,,,percent of total billed charges,pays at 18% of total charges,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,20,
MESH PHYSIOMESH 20 X 25,3636600,CDM,278,RC,C1781,HCPCS,Outpatient,,,2700,1620,,486,18,,,percent of total billed charges,pays at 18% of total charges,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,486,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1890,70,,,percent of total billed charges,70% of total billed charges,2025,75,,,percent of total billed charges,75% of total billed charges,1350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1620,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2700,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,465.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1215,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1890,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1620,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1026,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1890,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,423.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.09,2700,
SLEEVE FEMORAL,3636602,CDM,278,RC,C1776,HCPCS,Outpatient,,,3700,2220,,666,18,,,percent of total billed charges,pays at 18% of total charges,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,666,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2590,70,,,percent of total billed charges,70% of total billed charges,2775,75,,,percent of total billed charges,75% of total billed charges,1850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2220,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3700,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,637.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1665,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2590,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2220,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1406,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2590,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1776,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,579.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.79,3700,
ACETABULAR LINER,3636603,CDM,278,RC,C1776,HCPCS,Outpatient,,,3560,2136,,640.8,18,,,percent of total billed charges,pays at 18% of total charges,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,640.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2492,70,,,percent of total billed charges,70% of total billed charges,2670,75,,,percent of total billed charges,75% of total billed charges,1780,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2848,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2136,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3560,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,613.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1602,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2492,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2136,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1352.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2492,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1708.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,557.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.85,3560,
HEAD FEMORAL,3636604,CDM,278,RC,C1776,HCPCS,Outpatient,,,3900,2340,,702,18,,,percent of total billed charges,pays at 18% of total charges,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,70,,,percent of total billed charges,70% of total billed charges,2925,75,,,percent of total billed charges,75% of total billed charges,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,671.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1755,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1482,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.13,3900,
SLEEVE,3636605,CDM,278,RC,C1776,HCPCS,Outpatient,,,450,270,,81,18,,,percent of total billed charges,pays at 18% of total charges,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,450,
FEMORAL COMPONENT,3636606,CDM,278,RC,C1776,HCPCS,Outpatient,,,9700,5820,,1746,18,,,percent of total billed charges,pays at 18% of total charges,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1746,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6790,70,,,percent of total billed charges,70% of total billed charges,7275,75,,,percent of total billed charges,75% of total billed charges,4850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5820,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9700,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1671.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4365,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6790,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5820,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3686,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6790,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4656,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1519.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1519.99,9700,
BLADE SAW,3636607,CDM,272,RC,,,Outpatient,,,773,463.8,,139.14,18,,,percent of total billed charges,pays at 18% of total charges,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.5,50,,,percent of total billed charges,pays at 50% of total billed charges,541.1,70,,,percent of total billed charges,70% of total billed charges,579.75,75,,,percent of total billed charges,75% of total billed charges,386.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,618.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,591.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,541.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,463.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,293.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,541.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,773,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,695.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,773,
GUN MENISCAL,3636608,CDM,272,RC,,,Outpatient,,,285,171,,51.3,18,,,percent of total billed charges,pays at 18% of total charges,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,50,,,percent of total billed charges,pays at 50% of total billed charges,199.5,70,,,percent of total billed charges,70% of total billed charges,213.75,75,,,percent of total billed charges,75% of total billed charges,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,285,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,285,
BONE FLAP CUSTOM,3636609,CDM,278,RC,,,Outpatient,,,11700,7020,,2106,18,,,percent of total billed charges,pays at 18% of total charges,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2106,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5850,50,,,percent of total billed charges,pays at 50% of total billed charges,8190,70,,,percent of total billed charges,70% of total billed charges,8775,75,,,percent of total billed charges,75% of total billed charges,5850,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7020,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11700,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5265,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7020,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4446,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5616,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1833.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.39,11700,
SURGICEL FIBRILLAR,3636610,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
KIT TENDON REPAIR,3636611,CDM,278,RC,C1713,HCPCS,Outpatient,,,2230,1338,,401.4,18,,,percent of total billed charges,pays at 18% of total charges,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,401.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1561,70,,,percent of total billed charges,70% of total billed charges,1672.5,75,,,percent of total billed charges,75% of total billed charges,1115,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1338,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2230,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,384.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1561,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1338,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,847.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1561,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1070.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2230,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2230,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,349.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.44,2230,
MATRIX BILAYER MEMBRANE,3636612,CDM,278,RC,C1763,HCPCS,Outpatient,,,525,315,,94.5,18,,,percent of total billed charges,pays at 18% of total charges,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,70,,,percent of total billed charges,70% of total billed charges,393.75,75,,,percent of total billed charges,75% of total billed charges,262.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,525,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,525,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.27,525,
SYSTEM CLOSURE CT,3636613,CDM,272,RC,,,Outpatient,,,192,115.2,,34.56,18,,,percent of total billed charges,pays at 18% of total charges,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96,50,,,percent of total billed charges,pays at 50% of total billed charges,134.4,70,,,percent of total billed charges,70% of total billed charges,144,75,,,percent of total billed charges,75% of total billed charges,96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,192,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,172.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,192,
STIMULATOR NEURO,3636614,CDM,278,RC,C1767,HCPCS,Outpatient,,,19000,11400,,3420,18,,,percent of total billed charges,pays at 18% of total charges,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3420,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13300,70,,,percent of total billed charges,70% of total billed charges,14250,75,,,percent of total billed charges,75% of total billed charges,9500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11400,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19000,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3273.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8550,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11400,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7220,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13300,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2977.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2977.3,19000,
ANTENNA,3636615,CDM,272,RC,,,Outpatient,,,120,72,,21.6,18,,,percent of total billed charges,pays at 18% of total charges,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60,50,,,percent of total billed charges,pays at 50% of total billed charges,84,70,,,percent of total billed charges,70% of total billed charges,90,75,,,percent of total billed charges,75% of total billed charges,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,120,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,108,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.8,120,
ANCHOR SUTURE TITAN,3636616,CDM,278,RC,C1713,HCPCS,Outpatient,,,225,135,,40.5,18,,,percent of total billed charges,pays at 18% of total charges,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,225,
SLING PELVIC MALE,3636617,CDM,278,RC,C1771,HCPCS,Outpatient,,,6312,3787.2,,1136.16,18,,,percent of total billed charges,pays at 18% of total charges,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1136.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4418.4,70,,,percent of total billed charges,70% of total billed charges,4734,75,,,percent of total billed charges,75% of total billed charges,3156,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5049.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3787.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6312,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1087.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2840.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4418.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3787.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2398.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4418.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3029.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6312,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6312,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.09,6312,
ALLOGRAFT NUCEL MED,3636618,CDM,278,RC,V2790,HCPCS,Outpatient,,,2860,1716,,514.8,18,,,percent of total billed charges,pays at 18% of total charges,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,514.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1430,50,,,percent of total billed charges,pays at 50% of total billed charges,2002,70,,,percent of total billed charges,70% of total billed charges,2145,75,,,percent of total billed charges,75% of total billed charges,1430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2860,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,492.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1716,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1086.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2002,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1372.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.16,2860,
HUMERAL STEM,3636619,CDM,278,RC,C1776,HCPCS,Outpatient,,,7878,4726.8,,1418.04,18,,,percent of total billed charges,pays at 18% of total charges,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1418.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5514.6,70,,,percent of total billed charges,70% of total billed charges,5908.5,75,,,percent of total billed charges,75% of total billed charges,3939,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4726.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7878,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1357.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3545.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5514.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4726.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2993.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5514.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3781.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7878,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7878,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1234.48,7878,
HUMERAL TRAY,3636620,CDM,278,RC,C1776,HCPCS,Outpatient,,,2885,1731,,519.3,18,,,percent of total billed charges,pays at 18% of total charges,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2019.5,70,,,percent of total billed charges,70% of total billed charges,2163.75,75,,,percent of total billed charges,75% of total billed charges,1442.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2308,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1731,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2885,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,497.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1298.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2019.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1731,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1096.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2019.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1384.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2885,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2885,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,452.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,452.08,2885,
GLENOSPHERE BASEPLATE,3636621,CDM,278,RC,C1776,HCPCS,Outpatient,,,2610,1566,,469.8,18,,,percent of total billed charges,pays at 18% of total charges,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1827,70,,,percent of total billed charges,70% of total billed charges,1957.5,75,,,percent of total billed charges,75% of total billed charges,1305,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1566,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2610,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,449.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1827,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1566,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,991.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1827,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2610,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2610,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.99,2610,
VEIN HUMAN,3636622,CDM,278,RC,C1762,HCPCS,Outpatient,,,6315,3789,,1136.7,18,,,percent of total billed charges,pays at 18% of total charges,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1136.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4420.5,70,,,percent of total billed charges,70% of total billed charges,4736.25,75,,,percent of total billed charges,75% of total billed charges,3157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5052,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3789,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6315,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1088.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2841.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4420.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3789,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2399.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4420.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3031.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,989.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.56,6315,
CHRONOS GRANULES 20CC,3636623,CDM,278,RC,,,Outpatient,,,1404,842.4,,252.72,18,,,percent of total billed charges,pays at 18% of total charges,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,702,50,,,percent of total billed charges,pays at 50% of total billed charges,982.8,70,,,percent of total billed charges,70% of total billed charges,1053,75,,,percent of total billed charges,75% of total billed charges,702,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,842.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1404,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,982.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,842.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,982.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.01,1404,
DEVICE TROCH REATTACH LNG,3636624,CDM,278,RC,C1713,HCPCS,Outpatient,,,3670,2202,,660.6,18,,,percent of total billed charges,pays at 18% of total charges,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,660.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2569,70,,,percent of total billed charges,70% of total billed charges,2752.5,75,,,percent of total billed charges,75% of total billed charges,1835,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2936,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2202,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3670,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,632.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1651.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2569,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2202,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1394.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2569,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1761.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3670,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3670,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,575.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.09,3670,
DEVICE MENISCAL REPAIR 7X,3636625,CDM,278,RC,C1713,HCPCS,Outpatient,,,1825,1095,,328.5,18,,,percent of total billed charges,pays at 18% of total charges,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1277.5,70,,,percent of total billed charges,70% of total billed charges,1368.75,75,,,percent of total billed charges,75% of total billed charges,912.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1460,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1095,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1825,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,314.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,821.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1277.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1095,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1277.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.98,1825,
DEVICE MENISCAL REPAIR 4X,3636626,CDM,278,RC,C1713,HCPCS,Outpatient,,,1425,855,,256.5,18,,,percent of total billed charges,pays at 18% of total charges,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,997.5,70,,,percent of total billed charges,70% of total billed charges,1068.75,75,,,percent of total billed charges,75% of total billed charges,712.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,855,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1425,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,245.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,997.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,855,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,541.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,997.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1425,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1425,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.3,1425,
CATH SINUS BALLOON,3636627,CDM,272,RC,,,Outpatient,,,1075,645,,193.5,18,,,percent of total billed charges,pays at 18% of total charges,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,537.5,50,,,percent of total billed charges,pays at 50% of total billed charges,752.5,70,,,percent of total billed charges,70% of total billed charges,806.25,75,,,percent of total billed charges,75% of total billed charges,537.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,645,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,822.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,752.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,752.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1075,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,967.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.45,1075,
CATH SINUS GUIDE FLEX,3636628,CDM,272,RC,,,Outpatient,,,580,348,,104.4,18,,,percent of total billed charges,pays at 18% of total charges,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290,50,,,percent of total billed charges,pays at 50% of total billed charges,406,70,,,percent of total billed charges,70% of total billed charges,435,75,,,percent of total billed charges,75% of total billed charges,290,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,348,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,406,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,348,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,406,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,580,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,522,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,580,
TUBING EXT HIGH PRESSURE,3636629,CDM,272,RC,,,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
CATH SINUS GUIDE,3636630,CDM,272,RC,,,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
DEVICE INFLATION SINUS,3636631,CDM,272,RC,,,Outpatient,,,225,135,,40.5,18,,,percent of total billed charges,pays at 18% of total charges,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,50,,,percent of total billed charges,pays at 50% of total billed charges,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,202.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,225,
SYS ILLUMINATION SINUS,3636632,CDM,272,RC,,,Outpatient,,,675,405,,121.5,18,,,percent of total billed charges,pays at 18% of total charges,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.5,50,,,percent of total billed charges,pays at 50% of total billed charges,472.5,70,,,percent of total billed charges,70% of total billed charges,506.25,75,,,percent of total billed charges,75% of total billed charges,337.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,516.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,472.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,472.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,675,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,607.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.77,675,
TENDON GRACILIS,3636633,CDM,278,RC,C1762,HCPCS,Outpatient,,,1650,990,,297,18,,,percent of total billed charges,pays at 18% of total charges,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,297,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1155,70,,,percent of total billed charges,70% of total billed charges,1237.5,75,,,percent of total billed charges,75% of total billed charges,825,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,990,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1650,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,284.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,627,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1155,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,792,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.56,1650,
OMNISPAN NEEDLE,3636634,CDM,278,RC,C1713,HCPCS,Outpatient,,,448.5,269.1,,80.73,18,,,percent of total billed charges,pays at 18% of total charges,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.95,70,,,percent of total billed charges,70% of total billed charges,336.38,75,,,percent of total billed charges,75% of total billed charges,224.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,358.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,448.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,448.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,448.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,448.5,
KIT ALLOGRAFT SIZING,3636635,CDM,272,RC,,,Outpatient,,,975,585,,175.5,18,,,percent of total billed charges,pays at 18% of total charges,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.5,50,,,percent of total billed charges,pays at 50% of total billed charges,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,745.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,877.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
ALLOGRAFT NUCEL SM,3636636,CDM,278,RC,V2790,HCPCS,Outpatient,,,975,585,,175.5,18,,,percent of total billed charges,pays at 18% of total charges,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.5,50,,,percent of total billed charges,pays at 50% of total billed charges,682.5,70,,,percent of total billed charges,70% of total billed charges,731.25,75,,,percent of total billed charges,75% of total billed charges,487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,780,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,167.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,682.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,975,
ALLOGRAFT NUCEL LGE,3636637,CDM,278,RC,V2790,HCPCS,Outpatient,,,4550,2730,,819,18,,,percent of total billed charges,pays at 18% of total charges,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2275,50,,,percent of total billed charges,pays at 50% of total billed charges,3185,70,,,percent of total billed charges,70% of total billed charges,3412.5,75,,,percent of total billed charges,75% of total billed charges,2275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4550,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,783.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.99,4550,
ALLOGRAFT NUCEL XL,3636638,CDM,278,RC,V2790,HCPCS,Outpatient,,,5850,3510,,1053,18,,,percent of total billed charges,pays at 18% of total charges,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1053,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2925,50,,,percent of total billed charges,pays at 50% of total billed charges,4095,70,,,percent of total billed charges,70% of total billed charges,4387.5,75,,,percent of total billed charges,75% of total billed charges,2925,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1007.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2632.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4095,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2223,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4095,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2808,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,916.7,5850,
PATCH TYMPANIC MEMBRANE TM,3636639,CDM,278,RC,,,Outpatient,,,276,165.6,,49.68,18,,,percent of total billed charges,pays at 18% of total charges,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138,50,,,percent of total billed charges,pays at 50% of total billed charges,193.2,70,,,percent of total billed charges,70% of total billed charges,207,75,,,percent of total billed charges,75% of total billed charges,138,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,276,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,276,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.25,276,
BONE INSERT,3636640,CDM,278,RC,C1762,HCPCS,Outpatient,,,800,480,,144,18,,,percent of total billed charges,pays at 18% of total charges,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560,70,,,percent of total billed charges,70% of total billed charges,600,75,,,percent of total billed charges,75% of total billed charges,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.36,800,
TWIST DRILL CALIB,3636642,CDM,272,RC,,,Outpatient,,,211,126.6,,37.98,18,,,percent of total billed charges,pays at 18% of total charges,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.5,50,,,percent of total billed charges,pays at 50% of total billed charges,147.7,70,,,percent of total billed charges,70% of total billed charges,158.25,75,,,percent of total billed charges,75% of total billed charges,105.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,211,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.06,211,
DRIVER PEG,3636643,CDM,272,RC,,,Outpatient,,,48,28.8,,8.64,18,,,percent of total billed charges,pays at 18% of total charges,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24,50,,,percent of total billed charges,pays at 50% of total billed charges,33.6,70,,,percent of total billed charges,70% of total billed charges,36,75,,,percent of total billed charges,75% of total billed charges,24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,48,
DRILL BIT DELTA,3636644,CDM,272,RC,,,Outpatient,,,164,98.4,,29.52,18,,,percent of total billed charges,pays at 18% of total charges,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.7,164,
DRILL BIT MODIFIED,3636645,CDM,272,RC,,,Outpatient,,,136,81.6,,24.48,18,,,percent of total billed charges,pays at 18% of total charges,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68,50,,,percent of total billed charges,pays at 50% of total billed charges,95.2,70,,,percent of total billed charges,70% of total billed charges,102,75,,,percent of total billed charges,75% of total billed charges,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,136,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,136,
DRILL BIT CANN,3636646,CDM,272,RC,,,Outpatient,,,447,268.2,,80.46,18,,,percent of total billed charges,pays at 18% of total charges,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,50,,,percent of total billed charges,pays at 50% of total billed charges,312.9,70,,,percent of total billed charges,70% of total billed charges,335.25,75,,,percent of total billed charges,75% of total billed charges,223.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,357.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,341.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,312.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,447,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,402.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.04,447,
DRILL PIN CALIB,3636647,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
PIN LCKG PRIMARY,3636648,CDM,272,RC,,,Outpatient,,,448,268.8,,80.64,18,,,percent of total billed charges,pays at 18% of total charges,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224,50,,,percent of total billed charges,pays at 50% of total billed charges,313.6,70,,,percent of total billed charges,70% of total billed charges,336,75,,,percent of total billed charges,75% of total billed charges,224,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,358.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,342.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,268.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,448,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,403.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.2,448,
PLATE FIBULA LCKG,3636649,CDM,278,RC,C1713,HCPCS,Outpatient,,,320,192,,57.6,18,,,percent of total billed charges,pays at 18% of total charges,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,160,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,320,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,320,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,320,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.14,320,
SCREW CANC FTH,3636650,CDM,278,RC,C1713,HCPCS,Outpatient,,,63.5,38.1,,11.43,18,,,percent of total billed charges,pays at 18% of total charges,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.45,70,,,percent of total billed charges,70% of total billed charges,47.63,75,,,percent of total billed charges,75% of total billed charges,31.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.95,63.5,
SCREW FRS,3636651,CDM,278,RC,C1713,HCPCS,Outpatient,,,306,183.6,,55.08,18,,,percent of total billed charges,pays at 18% of total charges,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.2,70,,,percent of total billed charges,70% of total billed charges,229.5,75,,,percent of total billed charges,75% of total billed charges,153,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.95,306,
SCREW HEXALOBE,3636652,CDM,278,RC,C1713,HCPCS,Outpatient,,,225,135,,40.5,18,,,percent of total billed charges,pays at 18% of total charges,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,225,
PATCHER TYMPANIC MEMBRANE,3636653,CDM,272,RC,,,Outpatient,,,87.3,52.38,,15.71,18,,,percent of total billed charges,pays at 18% of total charges,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.65,50,,,percent of total billed charges,pays at 50% of total billed charges,61.11,70,,,percent of total billed charges,70% of total billed charges,65.48,75,,,percent of total billed charges,75% of total billed charges,43.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,87.3,
DRIVER HEX CANN DISP,3636654,CDM,272,RC,,,Outpatient,,,435.5,261.3,,78.39,18,,,percent of total billed charges,pays at 18% of total charges,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,217.75,50,,,percent of total billed charges,pays at 50% of total billed charges,304.85,70,,,percent of total billed charges,70% of total billed charges,326.63,75,,,percent of total billed charges,75% of total billed charges,217.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,348.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,304.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,435.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,391.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.24,435.5,
SCREW FIXATION,3636655,CDM,278,RC,C1713,HCPCS,Outpatient,,,848,508.8,,152.64,18,,,percent of total billed charges,pays at 18% of total charges,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,593.6,70,,,percent of total billed charges,70% of total billed charges,636,75,,,percent of total billed charges,75% of total billed charges,424,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,848,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,593.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,508.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,593.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,848,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,848,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.88,848,
KIT PIN PF XL,3636656,CDM,278,RC,C1713,HCPCS,Outpatient,,,283.5,170.1,,51.03,18,,,percent of total billed charges,pays at 18% of total charges,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.45,70,,,percent of total billed charges,70% of total billed charges,212.63,75,,,percent of total billed charges,75% of total billed charges,141.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,283.5,
INTEGRA WOUND MATRIX PER SQ CM,3636657,CDM,636,RC,Q4104,HCPCS,Outpatient,,,20,12,,3.6,18,,,percent of total billed charges,pays at 18% of total charges,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,20,
PATCH WITTMAN SURG,3636660,CDM,278,RC,C1781,HCPCS,Outpatient,,,2067,1240.2,,372.06,18,,,percent of total billed charges,pays at 18% of total charges,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1446.9,70,,,percent of total billed charges,70% of total billed charges,1550.25,75,,,percent of total billed charges,75% of total billed charges,1033.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1653.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1240.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2067,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,930.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1446.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1240.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,785.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1446.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2067,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2067,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.9,2067,
DSG NASAL BIORESORBABLE 4CM,3636661,CDM,272,RC,,,Outpatient,,,185,111,,33.3,18,,,percent of total billed charges,pays at 18% of total charges,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.5,50,,,percent of total billed charges,pays at 50% of total billed charges,129.5,70,,,percent of total billed charges,70% of total billed charges,138.75,75,,,percent of total billed charges,75% of total billed charges,92.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,129.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,185,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,185,
DSG NASAL BIORESORBABLE 8CM,3636662,CDM,272,RC,,,Outpatient,,,275,165,,49.5,18,,,percent of total billed charges,pays at 18% of total charges,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,275,
SEAL DRIVE SHAFT DISP,3636663,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
ASSY TUBE RIA DISP,3636664,CDM,272,RC,,,Outpatient,,,707.68,424.61,,127.38,18,,,percent of total billed charges,pays at 18% of total charges,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,353.84,50,,,percent of total billed charges,pays at 50% of total billed charges,495.38,70,,,percent of total billed charges,70% of total billed charges,530.76,75,,,percent of total billed charges,75% of total billed charges,353.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,566.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,541.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,495.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,424.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,495.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,707.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,636.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,110.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.89,707.68,
FILTER GRAFT DISP,3636665,CDM,272,RC,,,Outpatient,,,470,282,,84.6,18,,,percent of total billed charges,pays at 18% of total charges,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,235,50,,,percent of total billed charges,pays at 50% of total billed charges,329,70,,,percent of total billed charges,70% of total billed charges,352.5,75,,,percent of total billed charges,75% of total billed charges,235,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,376,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,359.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,329,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,282,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,329,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,470,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,423,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.65,470,
INTEGRA WOUND MATRIX PER SQ CM,3636666,CDM,636,RC,Q4104,HCPCS,Outpatient,,,153,91.8,,27.54,18,,,percent of total billed charges,pays at 18% of total charges,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,50,,,percent of total billed charges,pays at 50% of total billed charges,107.1,70,,,percent of total billed charges,70% of total billed charges,114.75,75,,,percent of total billed charges,75% of total billed charges,76.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,107.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,153,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,153,
INTEGRA WOUND MATRIX PER SQ CM,3636667,CDM,636,RC,Q4104,HCPCS,Outpatient,,,118,70.8,,21.24,18,,,percent of total billed charges,pays at 18% of total charges,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59,50,,,percent of total billed charges,pays at 50% of total billed charges,82.6,70,,,percent of total billed charges,70% of total billed charges,88.5,75,,,percent of total billed charges,75% of total billed charges,59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,118,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,118,
TUBE ET EMG REINFORCED,3636668,CDM,272,RC,,,Outpatient,,,537,322.2,,96.66,18,,,percent of total billed charges,pays at 18% of total charges,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.5,50,,,percent of total billed charges,pays at 50% of total billed charges,375.9,70,,,percent of total billed charges,70% of total billed charges,402.75,75,,,percent of total billed charges,75% of total billed charges,268.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,429.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,322.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,375.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,322.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,375.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,537,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,483.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.15,537,
STIMULATOR NEURO,3636669,CDM,278,RC,C1820,HCPCS,Outpatient,,,25874,15524.4,,4657.32,18,,,percent of total billed charges,pays at 18% of total charges,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4657.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18111.8,70,,,percent of total billed charges,70% of total billed charges,19405.5,75,,,percent of total billed charges,75% of total billed charges,12937,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20699.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15524.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25874,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4458.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11643.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18111.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15524.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9832.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,18111.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12419.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25874,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25874,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4054.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4054.46,25874,
BLADE PLASMA DISP,3636670,CDM,272,RC,,,Outpatient,,,407,244.2,,73.26,18,,,percent of total billed charges,pays at 18% of total charges,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.5,50,,,percent of total billed charges,pays at 50% of total billed charges,284.9,70,,,percent of total billed charges,70% of total billed charges,305.25,75,,,percent of total billed charges,75% of total billed charges,203.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,284.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,244.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,284.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,407,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,366.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.78,407,
SYS STIMULATOR CHARGING,3636671,CDM,274,RC,L8689,HCPCS,Outpatient,,,3200,1920,,7053.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1992.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1992.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1600,50,,,percent of total billed charges,pays at 50% of total billed charges,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,3586.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6974.17,350,,,Fee Schedule,350% of CMS OPPS Rate,2032.47,102,,,Fee Schedule,102% of CMS OPPS Rate,3200,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,551.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1992.62,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1216,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1992.62,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,3200,230,,,Fee Schedule,230% of CMS OPPS Rate,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1992.62,100,,,Fee Schedule,100% of CMS OPPS Rate,3200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,501.44,7053.87,
KIT LATARJET DISP,3636672,CDM,272,RC,,,Outpatient,,,855,513,,153.9,18,,,percent of total billed charges,pays at 18% of total charges,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.5,50,,,percent of total billed charges,pays at 50% of total billed charges,598.5,70,,,percent of total billed charges,70% of total billed charges,641.25,75,,,percent of total billed charges,75% of total billed charges,427.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,684,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,513,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,654.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,598.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,513,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,598.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,855,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,769.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.98,855,
DRILL BIT GLENOID,3636673,CDM,272,RC,,,Outpatient,,,1585,951,,285.3,18,,,percent of total billed charges,pays at 18% of total charges,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,285.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,792.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1109.5,70,,,percent of total billed charges,70% of total billed charges,1188.75,75,,,percent of total billed charges,75% of total billed charges,792.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1268,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,951,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1212.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1109.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,951,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,602.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1109.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1585,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1426.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.37,1585,
SET SCREW EXTRACTOR,3636674,CDM,272,RC,,,Outpatient,,,670,402,,120.6,18,,,percent of total billed charges,pays at 18% of total charges,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,335,50,,,percent of total billed charges,pays at 50% of total billed charges,469,70,,,percent of total billed charges,70% of total billed charges,502.5,75,,,percent of total billed charges,75% of total billed charges,335,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,536,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,402,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,512.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,469,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,469,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,670,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,603,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.99,670,
ELECTRODE BUTTON,3636675,CDM,272,RC,,,Outpatient,,,680,408,,122.4,18,,,percent of total billed charges,pays at 18% of total charges,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,50,,,percent of total billed charges,pays at 50% of total billed charges,476,70,,,percent of total billed charges,70% of total billed charges,510,75,,,percent of total billed charges,75% of total billed charges,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,408,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,680,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,612,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,680,
ELECTRODE LOOP,3636676,CDM,272,RC,,,Outpatient,,,680,408,,122.4,18,,,percent of total billed charges,pays at 18% of total charges,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,50,,,percent of total billed charges,pays at 50% of total billed charges,476,70,,,percent of total billed charges,70% of total billed charges,510,75,,,percent of total billed charges,75% of total billed charges,340,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,544,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,520.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,408,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,476,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,680,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,612,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,680,
TIP COAGULATION PLASMABLADE,3636677,CDM,272,RC,,,Outpatient,,,137.5,82.5,,24.75,18,,,percent of total billed charges,pays at 18% of total charges,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.75,50,,,percent of total billed charges,pays at 50% of total billed charges,96.25,70,,,percent of total billed charges,70% of total billed charges,103.13,75,,,percent of total billed charges,75% of total billed charges,68.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,137.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,123.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.55,137.5,
WEDGE PLEXOR M,3636678,CDM,278,RC,C1762,HCPCS,Outpatient,,,1950,1170,,351,18,,,percent of total billed charges,pays at 18% of total charges,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,70,,,percent of total billed charges,70% of total billed charges,1462.5,75,,,percent of total billed charges,75% of total billed charges,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,741,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.57,1950,
COVER PLEXOR M,3636679,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
KIT PLATELET CONCENTRATE,3636680,CDM,272,RC,,,Outpatient,,,2250,1350,,405,18,,,percent of total billed charges,pays at 18% of total charges,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,405,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1125,50,,,percent of total billed charges,pays at 50% of total billed charges,1575,70,,,percent of total billed charges,70% of total billed charges,1687.5,75,,,percent of total billed charges,75% of total billed charges,1125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1350,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1721.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1575,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1350,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,855,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1575,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2025,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,352.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.58,2250,
LEAD KIT,3636681,CDM,278,RC,C1781,HCPCS,Outpatient,,,8465,5079,,1523.7,18,,,percent of total billed charges,pays at 18% of total charges,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1523.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5925.5,70,,,percent of total billed charges,70% of total billed charges,6348.75,75,,,percent of total billed charges,75% of total billed charges,4232.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6772,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5079,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8465,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1458.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3809.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5925.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5079,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3216.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5925.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4063.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8465,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8465,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1326.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.47,8465,
RING CAPSULAR TENSION,3636684,CDM,278,RC,,,Outpatient,,,275,165,,49.5,18,,,percent of total billed charges,pays at 18% of total charges,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,275,
TRIAL SCREW DISP,3636685,CDM,272,RC,,,Outpatient,,,110,66,,19.8,18,,,percent of total billed charges,pays at 18% of total charges,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55,50,,,percent of total billed charges,pays at 50% of total billed charges,77,70,,,percent of total billed charges,70% of total billed charges,82.5,75,,,percent of total billed charges,75% of total billed charges,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,110,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.24,110,
SPACER VERTEBRAE,3636686,CDM,278,RC,C1821,HCPCS,Outpatient,,,10960,6576,,1972.8,18,,,percent of total billed charges,pays at 18% of total charges,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1972.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7672,70,,,percent of total billed charges,70% of total billed charges,8220,75,,,percent of total billed charges,75% of total billed charges,5480,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8768,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10960,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1888.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4932,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4164.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5260.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10960,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10960,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1717.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1717.43,10960,
SCREW SLF TPNG,3636687,CDM,278,RC,C1713,HCPCS,Outpatient,,,765,459,,137.7,18,,,percent of total billed charges,pays at 18% of total charges,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.5,70,,,percent of total billed charges,70% of total billed charges,573.75,75,,,percent of total billed charges,75% of total billed charges,382.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,612,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,459,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,535.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,535.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,765,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,765,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.88,765,
SLEEVE FEMORAL,3636688,CDM,278,RC,C1776,HCPCS,Outpatient,,,5250,3150,,945,18,,,percent of total billed charges,pays at 18% of total charges,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,945,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3675,70,,,percent of total billed charges,70% of total billed charges,3937.5,75,,,percent of total billed charges,75% of total billed charges,2625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,904.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2362.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3675,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1995,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3675,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2520,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.68,5250,
WEDGE PLEXUR BONE M LG,3636689,CDM,278,RC,C1762,HCPCS,Outpatient,,,3500,2100,,630,18,,,percent of total billed charges,pays at 18% of total charges,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,630,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2450,70,,,percent of total billed charges,70% of total billed charges,2625,75,,,percent of total billed charges,75% of total billed charges,1750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2100,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,603.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2450,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2100,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1330,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2450,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1680,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,548.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.45,3500,
WEDGE PLEXUR BONE M XLG,3636690,CDM,278,RC,C1762,HCPCS,Outpatient,,,4915,2949,,884.7,18,,,percent of total billed charges,pays at 18% of total charges,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,884.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3440.5,70,,,percent of total billed charges,70% of total billed charges,3686.25,75,,,percent of total billed charges,75% of total billed charges,2457.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3932,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2949,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4915,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,846.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2211.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3440.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2949,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1867.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3440.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2359.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4915,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4915,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,770.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.18,4915,
CURETTE REVERSE,3636691,CDM,272,RC,,,Outpatient,,,905,543,,162.9,18,,,percent of total billed charges,pays at 18% of total charges,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,452.5,50,,,percent of total billed charges,pays at 50% of total billed charges,633.5,70,,,percent of total billed charges,70% of total billed charges,678.75,75,,,percent of total billed charges,75% of total billed charges,452.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,724,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,692.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,633.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,633.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,905,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,814.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.81,905,
REAMER BONE,3636692,CDM,272,RC,,,Outpatient,,,745,447,,134.1,18,,,percent of total billed charges,pays at 18% of total charges,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.5,50,,,percent of total billed charges,pays at 50% of total billed charges,521.5,70,,,percent of total billed charges,70% of total billed charges,558.75,75,,,percent of total billed charges,75% of total billed charges,372.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,596,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,447,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,569.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,521.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,447,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,521.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,745,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,670.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.74,745,
PINS RETENTIVE,3636693,CDM,278,RC,C1713,HCPCS,Outpatient,,,530,318,,95.4,18,,,percent of total billed charges,pays at 18% of total charges,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371,70,,,percent of total billed charges,70% of total billed charges,397.5,75,,,percent of total billed charges,75% of total billed charges,265,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,424,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,91.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,371,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,530,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,530,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.05,530,
IMPLANT SI JOINT,3636694,CDM,278,RC,C1776,HCPCS,Outpatient,,,4975,2985,,895.5,18,,,percent of total billed charges,pays at 18% of total charges,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,895.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3482.5,70,,,percent of total billed charges,70% of total billed charges,3731.25,75,,,percent of total billed charges,75% of total billed charges,2487.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3980,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2985,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4975,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,857.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2238.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3482.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2985,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1890.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3482.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2388,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4975,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,779.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.58,4975,
DRILL CANNULATED,3636695,CDM,272,RC,,,Outpatient,,,910,546,,163.8,18,,,percent of total billed charges,pays at 18% of total charges,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455,50,,,percent of total billed charges,pays at 50% of total billed charges,637,70,,,percent of total billed charges,70% of total billed charges,682.5,75,,,percent of total billed charges,75% of total billed charges,455,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,696.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,637,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,546,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,637,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,910,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,819,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.6,910,
PIN PUSH,3636696,CDM,272,RC,,,Outpatient,,,170,102,,30.6,18,,,percent of total billed charges,pays at 18% of total charges,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,50,,,percent of total billed charges,pays at 50% of total billed charges,119,70,,,percent of total billed charges,70% of total billed charges,127.5,75,,,percent of total billed charges,75% of total billed charges,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,170,
BONE GRAFT FILLER,3636697,CDM,278,RC,C1762,HCPCS,Outpatient,,,6500,3900,,1170,18,,,percent of total billed charges,pays at 18% of total charges,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1170,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,70,,,percent of total billed charges,70% of total billed charges,4875,75,,,percent of total billed charges,75% of total billed charges,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1119.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2470,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1018.55,6500,
TISSUE CYMETRA INJ PER 1CC,3636698,CDM,636,RC,Q4112,HCPCS,Outpatient,,,250,150,,45,18,,,percent of total billed charges,pays at 18% of total charges,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125,50,,,percent of total billed charges,pays at 50% of total billed charges,175,70,,,percent of total billed charges,70% of total billed charges,187.5,75,,,percent of total billed charges,75% of total billed charges,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.18,250,
GAMMAGRAFT PER SQ CM,3636699,CDM,636,RC,Q4111,HCPCS,Outpatient,,,21,12.6,,3.78,18,,,percent of total billed charges,pays at 18% of total charges,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,21,
GAMMAGRAFT PER SQ CM,3636700,CDM,636,RC,Q4111,HCPCS,Outpatient,,,15,9,,2.7,18,,,percent of total billed charges,pays at 18% of total charges,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10.5,70,,,percent of total billed charges,70% of total billed charges,11.25,75,,,percent of total billed charges,75% of total billed charges,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,15,
GAMMAGRAFT PER SQ CM,3636701,CDM,636,RC,Q4111,HCPCS,Outpatient,,,9,5.4,,1.62,18,,,percent of total billed charges,pays at 18% of total charges,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.5,50,,,percent of total billed charges,pays at 50% of total billed charges,6.3,70,,,percent of total billed charges,70% of total billed charges,6.75,75,,,percent of total billed charges,75% of total billed charges,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,9,
KIT RESORBABLE BEAD,3636702,CDM,278,RC,,,Outpatient,,,815,489,,146.7,18,,,percent of total billed charges,pays at 18% of total charges,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,407.5,50,,,percent of total billed charges,pays at 50% of total billed charges,570.5,70,,,percent of total billed charges,70% of total billed charges,611.25,75,,,percent of total billed charges,75% of total billed charges,407.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,652,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,489,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,815,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,570.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,489,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,570.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,815,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,815,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.71,815,
SPLINT NAIL,3636703,CDM,272,RC,,,Outpatient,,,60,36,,10.8,18,,,percent of total billed charges,pays at 18% of total charges,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30,50,,,percent of total billed charges,pays at 50% of total billed charges,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,30,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,60,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.4,60,
PROSTHESIS EAR,3636704,CDM,278,RC,L8613,HCPCS,Outpatient,,,205,123,,36.9,18,,,percent of total billed charges,pays at 18% of total charges,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,102.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
SYS PENILE PROSTHESIS,3636705,CDM,278,RC,C1813,HCPCS,Outpatient,,,11800,7080,,2124,18,,,percent of total billed charges,pays at 18% of total charges,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2124,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8260,70,,,percent of total billed charges,70% of total billed charges,8850,75,,,percent of total billed charges,75% of total billed charges,5900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2033.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5310,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4484,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5664,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1849.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1849.06,11800,
IMPLANT BAHA AND PROCESSOR,3636707,CDM,278,RC,L8690,HCPCS,Outpatient,,,7185,4311,,1293.3,18,,,percent of total billed charges,pays at 18% of total charges,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1293.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3592.5,50,,,percent of total billed charges,pays at 50% of total billed charges,5029.5,70,,,percent of total billed charges,70% of total billed charges,5388.75,75,,,percent of total billed charges,75% of total billed charges,3592.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5748,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4311,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7185,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1237.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3233.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5029.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4311,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2730.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5029.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3448.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7185,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7185,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1125.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.89,7185,
KIT SUPPLY BAHA PROCEDURE,3636708,CDM,272,RC,,,Outpatient,,,635,381,,114.3,18,,,percent of total billed charges,pays at 18% of total charges,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.5,50,,,percent of total billed charges,pays at 50% of total billed charges,444.5,70,,,percent of total billed charges,70% of total billed charges,476.25,75,,,percent of total billed charges,75% of total billed charges,317.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,485.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,444.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,381,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,444.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,635,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,571.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.5,635,
DRILL WIDENING,3636709,CDM,272,RC,,,Outpatient,,,337.5,202.5,,60.75,18,,,percent of total billed charges,pays at 18% of total charges,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,50,,,percent of total billed charges,pays at 50% of total billed charges,236.25,70,,,percent of total billed charges,70% of total billed charges,253.13,75,,,percent of total billed charges,75% of total billed charges,168.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,236.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,236.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,337.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,303.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.89,337.5,
DRILL GUIDE,3636710,CDM,272,RC,,,Outpatient,,,337.5,202.5,,60.75,18,,,percent of total billed charges,pays at 18% of total charges,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.75,50,,,percent of total billed charges,pays at 50% of total billed charges,236.25,70,,,percent of total billed charges,70% of total billed charges,253.13,75,,,percent of total billed charges,75% of total billed charges,168.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,236.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,236.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,337.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,303.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.89,337.5,
BLADE BAHA,3636711,CDM,272,RC,,,Outpatient,,,112.5,67.5,,20.25,18,,,percent of total billed charges,pays at 18% of total charges,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,50,,,percent of total billed charges,pays at 50% of total billed charges,78.75,70,,,percent of total billed charges,70% of total billed charges,84.38,75,,,percent of total billed charges,75% of total billed charges,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,112.5,
CAP HEALING,3636712,CDM,272,RC,,,Outpatient,,,76,45.6,,13.68,18,,,percent of total billed charges,pays at 18% of total charges,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,50,,,percent of total billed charges,pays at 50% of total billed charges,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,76,
PUNCH BIOPSY,3636713,CDM,272,RC,,,Outpatient,,,22,13.2,,3.96,18,,,percent of total billed charges,pays at 18% of total charges,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,50,,,percent of total billed charges,pays at 50% of total billed charges,15.4,70,,,percent of total billed charges,70% of total billed charges,16.5,75,,,percent of total billed charges,75% of total billed charges,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.45,22,
DSG ALLEVYN NON ADHESIVE,3636714,CDM,272,RC,,,Outpatient,,,20,12,,3.6,18,,,percent of total billed charges,pays at 18% of total charges,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,20,
ALLOGRAFT AMNIOTIC MEMBRANE DISC,3636715,CDM,278,RC,V2790,HCPCS,Outpatient,,,450,270,,81,18,,,percent of total billed charges,pays at 18% of total charges,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,50,,,percent of total billed charges,pays at 50% of total billed charges,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,450,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,450,
ALLOGRAFT AMNIOTIC MEMBRANE WRAP,3636716,CDM,278,RC,V2790,HCPCS,Outpatient,,,1635,981,,294.3,18,,,percent of total billed charges,pays at 18% of total charges,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,817.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1144.5,70,,,percent of total billed charges,70% of total billed charges,1226.25,75,,,percent of total billed charges,75% of total billed charges,817.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1308,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,981,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1635,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,281.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1144.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,981,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,621.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1144.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1635,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1635,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,256.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.2,1635,
SYS IMPLANT ELBOW,3636717,CDM,278,RC,C1776,HCPCS,Outpatient,,,1950,1170,,351,18,,,percent of total billed charges,pays at 18% of total charges,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,70,,,percent of total billed charges,70% of total billed charges,1462.5,75,,,percent of total billed charges,75% of total billed charges,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,741,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.57,1950,
GUIDE IMPLANT SIZING,3636718,CDM,272,RC,,,Outpatient,,,360,216,,64.8,18,,,percent of total billed charges,pays at 18% of total charges,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,50,,,percent of total billed charges,pays at 50% of total billed charges,252,70,,,percent of total billed charges,70% of total billed charges,270,75,,,percent of total billed charges,75% of total billed charges,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,360,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,360,
KIT DRILL DISPOSABLE,3636719,CDM,272,RC,,,Outpatient,,,515,309,,92.7,18,,,percent of total billed charges,pays at 18% of total charges,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.5,50,,,percent of total billed charges,pays at 50% of total billed charges,360.5,70,,,percent of total billed charges,70% of total billed charges,386.25,75,,,percent of total billed charges,75% of total billed charges,257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,360.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,463.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.7,515,
IMPLANT METATARSAL,3636720,CDM,278,RC,C1776,HCPCS,Outpatient,,,1950,1170,,351,18,,,percent of total billed charges,pays at 18% of total charges,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365,70,,,percent of total billed charges,70% of total billed charges,1462.5,75,,,percent of total billed charges,75% of total billed charges,975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1950,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1170,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,741,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1365,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.57,1950,
MESH TISSUE STRATTICE PER SQ CM,3636721,CDM,636,RC,Q4130,HCPCS,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
TISSUE ALLODERM PER SQ CM,3636722,CDM,636,RC,Q4116,HCPCS,Outpatient,,,47,28.2,,8.46,18,,,percent of total billed charges,pays at 18% of total charges,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.5,50,,,percent of total billed charges,pays at 50% of total billed charges,32.9,70,,,percent of total billed charges,70% of total billed charges,35.25,75,,,percent of total billed charges,75% of total billed charges,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.36,47,
NAIL FEMORAL,3636723,CDM,278,RC,C1713,HCPCS,Outpatient,,,3400,2040,,612,18,,,percent of total billed charges,pays at 18% of total charges,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,612,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2380,70,,,percent of total billed charges,70% of total billed charges,2550,75,,,percent of total billed charges,75% of total billed charges,1700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3400,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2040,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1292,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1632,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,532.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.78,3400,
SCREW,3636724,CDM,278,RC,C1713,HCPCS,Outpatient,,,1125,675,,202.5,18,,,percent of total billed charges,pays at 18% of total charges,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.5,70,,,percent of total billed charges,70% of total billed charges,843.75,75,,,percent of total billed charges,75% of total billed charges,562.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1125,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,787.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,675,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,787.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.29,1125,
COLLAGEN GRAFT NERVE PER CM,3636725,CDM,278,RC,C9353,HCPCS,Outpatient,,,637,382.2,,114.66,18,,,percent of total billed charges,pays at 18% of total charges,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.9,70,,,percent of total billed charges,70% of total billed charges,477.75,75,,,percent of total billed charges,75% of total billed charges,318.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,445.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,445.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,637,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,637,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.82,637,
COLLAGEN GRAFT NERVE PER CM,3636726,CDM,278,RC,C9353,HCPCS,Outpatient,,,802,481.2,,144.36,18,,,percent of total billed charges,pays at 18% of total charges,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.4,70,,,percent of total billed charges,70% of total billed charges,601.5,75,,,percent of total billed charges,75% of total billed charges,401,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,561.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,481.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,561.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,802,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,802,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.67,802,
COLLAGEN GRAFT NERVE PER CM,3636727,CDM,278,RC,C9353,HCPCS,Outpatient,,,1083,649.8,,194.94,18,,,percent of total billed charges,pays at 18% of total charges,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.1,70,,,percent of total billed charges,70% of total billed charges,812.25,75,,,percent of total billed charges,75% of total billed charges,541.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,186.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,758.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,649.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,758.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1083,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1083,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.71,1083,
SEALANT ARISTA,3636728,CDM,272,RC,,,Outpatient,,,315,189,,56.7,18,,,percent of total billed charges,pays at 18% of total charges,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,50,,,percent of total billed charges,pays at 50% of total billed charges,220.5,70,,,percent of total billed charges,70% of total billed charges,236.25,75,,,percent of total billed charges,75% of total billed charges,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,283.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.36,315,
APPLICATOR ARISTA SEALANT,3636729,CDM,272,RC,,,Outpatient,,,35,21,,6.3,18,,,percent of total billed charges,pays at 18% of total charges,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.5,50,,,percent of total billed charges,pays at 50% of total billed charges,24.5,70,,,percent of total billed charges,70% of total billed charges,26.25,75,,,percent of total billed charges,75% of total billed charges,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,35,
KIT SEALANT ARISTA ENT,3636730,CDM,272,RC,,,Outpatient,,,860,516,,154.8,18,,,percent of total billed charges,pays at 18% of total charges,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,154.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,430,50,,,percent of total billed charges,pays at 50% of total billed charges,602,70,,,percent of total billed charges,70% of total billed charges,645,75,,,percent of total billed charges,75% of total billed charges,430,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,688,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,602,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,516,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,326.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,602,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,860,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,774,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.76,860,
FIXATOR ANKLE SET,3636731,CDM,272,RC,,,Outpatient,,,8000,4800,,1440,18,,,percent of total billed charges,pays at 18% of total charges,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4000,50,,,percent of total billed charges,pays at 50% of total billed charges,5600,70,,,percent of total billed charges,70% of total billed charges,6000,75,,,percent of total billed charges,75% of total billed charges,4000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3600,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3040,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7200,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1253.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1253.6,8000,
GUIDE RESECTION ORTHO,3636732,CDM,272,RC,,,Outpatient,,,1375,825,,247.5,18,,,percent of total billed charges,pays at 18% of total charges,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,687.5,50,,,percent of total billed charges,pays at 50% of total billed charges,962.5,70,,,percent of total billed charges,70% of total billed charges,1031.25,75,,,percent of total billed charges,75% of total billed charges,687.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,825,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1051.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,962.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,825,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,522.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,962.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1237.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.46,1375,
SPACER TIBIAL,3636733,CDM,278,RC,C1713,HCPCS,Outpatient,,,4300,2580,,774,18,,,percent of total billed charges,pays at 18% of total charges,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,774,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3010,70,,,percent of total billed charges,70% of total billed charges,3225,75,,,percent of total billed charges,75% of total billed charges,2150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2580,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,740.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1935,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3010,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2580,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1634,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3010,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2064,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.81,4300,
SYS SINUPLASTY BALLOON,3636734,CDM,272,RC,,,Outpatient,,,2180,1308,,392.4,18,,,percent of total billed charges,pays at 18% of total charges,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1090,50,,,percent of total billed charges,pays at 50% of total billed charges,1526,70,,,percent of total billed charges,70% of total billed charges,1635,75,,,percent of total billed charges,75% of total billed charges,1090,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1744,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1667.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,981,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1526,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1308,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,828.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1526,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2180,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1962,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.61,2180,
CAGE PEEK,3636735,CDM,278,RC,,,Outpatient,,,7900,4740,,1422,18,,,percent of total billed charges,pays at 18% of total charges,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1422,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3950,50,,,percent of total billed charges,pays at 50% of total billed charges,5530,70,,,percent of total billed charges,70% of total billed charges,5925,75,,,percent of total billed charges,75% of total billed charges,3950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4740,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3555,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5530,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4740,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3002,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5530,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3792,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1237.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1237.93,7900,
DILATOR STIMULATED,3636736,CDM,272,RC,,,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390,50,,,percent of total billed charges,pays at 50% of total billed charges,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,702,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
RETROPASSER,3636737,CDM,272,RC,,,Outpatient,,,220.5,132.3,,39.69,18,,,percent of total billed charges,pays at 18% of total charges,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.25,50,,,percent of total billed charges,pays at 50% of total billed charges,154.35,70,,,percent of total billed charges,70% of total billed charges,165.38,75,,,percent of total billed charges,75% of total billed charges,110.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,154.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.55,220.5,
FIXATOR EXTERNAL ORTHO,3636738,CDM,272,RC,,,Outpatient,,,825,495,,148.5,18,,,percent of total billed charges,pays at 18% of total charges,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.5,50,,,percent of total billed charges,pays at 50% of total billed charges,577.5,70,,,percent of total billed charges,70% of total billed charges,618.75,75,,,percent of total billed charges,75% of total billed charges,412.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,495,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,631.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,495,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,577.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,825,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,742.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.28,825,
BIT COUNTERSINK,3636739,CDM,272,RC,,,Outpatient,,,560,336,,100.8,18,,,percent of total billed charges,pays at 18% of total charges,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280,50,,,percent of total billed charges,pays at 50% of total billed charges,392,70,,,percent of total billed charges,70% of total billed charges,420,75,,,percent of total billed charges,75% of total billed charges,280,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,448,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,336,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,428.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,392,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,336,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,392,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,560,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,504,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.75,560,
SCREW PEEK INTERFERENCE,3636740,CDM,278,RC,C1713,HCPCS,Outpatient,,,466,279.6,,83.88,18,,,percent of total billed charges,pays at 18% of total charges,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.2,70,,,percent of total billed charges,70% of total billed charges,349.5,75,,,percent of total billed charges,75% of total billed charges,233,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,326.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,326.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,466,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,466,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,466,
KIT GUIDE PIN,3636741,CDM,272,RC,,,Outpatient,,,459,275.4,,82.62,18,,,percent of total billed charges,pays at 18% of total charges,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.5,50,,,percent of total billed charges,pays at 50% of total billed charges,321.3,70,,,percent of total billed charges,70% of total billed charges,344.25,75,,,percent of total billed charges,75% of total billed charges,229.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,275.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,351.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,321.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,321.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,459,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,413.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.93,459,
ERASER HEMOSTATIC BRUSH,3636742,CDM,272,RC,,,Outpatient,,,21,12.6,,3.78,18,,,percent of total billed charges,pays at 18% of total charges,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,21,
CORD HEMOSTATIC,3636743,CDM,272,RC,,,Outpatient,,,35,21,,6.3,18,,,percent of total billed charges,pays at 18% of total charges,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.5,50,,,percent of total billed charges,pays at 50% of total billed charges,24.5,70,,,percent of total billed charges,70% of total billed charges,26.25,75,,,percent of total billed charges,75% of total billed charges,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,35,
SCREW CENTRAL REVERSE,3636744,CDM,278,RC,C1713,HCPCS,Outpatient,,,327,196.2,,58.86,18,,,percent of total billed charges,pays at 18% of total charges,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.9,70,,,percent of total billed charges,70% of total billed charges,245.25,75,,,percent of total billed charges,75% of total billed charges,163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,228.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,228.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,327,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,327,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.24,327,
MESH STRATTICE 10 X 16 WASTE PER SQ CM,3636745,CDM,636,RC,Q4130,HCPCS,Outpatient,,,42,25.2,,7.56,18,,,percent of total billed charges,pays at 18% of total charges,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,42,
DEVICE WOUND CLOSURE,3636746,CDM,272,RC,,,Outpatient,,,1200,720,,216,18,,,percent of total billed charges,pays at 18% of total charges,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,600,50,,,percent of total billed charges,pays at 50% of total billed charges,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,456,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.04,1200,
TISSUE CYMETRA 1CC WASTE PER CC,3636747,CDM,636,RC,Q4112,HCPCS,Outpatient,,,250,150,,45,18,,,percent of total billed charges,pays at 18% of total charges,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125,50,,,percent of total billed charges,pays at 50% of total billed charges,175,70,,,percent of total billed charges,70% of total billed charges,187.5,75,,,percent of total billed charges,75% of total billed charges,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.18,250,
TISSUE ALLODERM 4 X 16 WASTE PER SQ CM,3636748,CDM,636,RC,Q4116,HCPCS,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
TISSUE ALLODERM 6 X 12 WASTE PER SQ CM,3636749,CDM,636,RC,Q4116,HCPCS,Outpatient,,,47,28.2,,8.46,18,,,percent of total billed charges,pays at 18% of total charges,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.5,50,,,percent of total billed charges,pays at 50% of total billed charges,32.9,70,,,percent of total billed charges,70% of total billed charges,35.25,75,,,percent of total billed charges,75% of total billed charges,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.36,47,
DERMACELL WD MATRIX WASTE PER SQ CM,3636751,CDM,636,RC,Q4122,HCPCS,Outpatient,,,117,70.2,,21.06,18,,,percent of total billed charges,pays at 18% of total charges,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,50,,,percent of total billed charges,pays at 50% of total billed charges,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,117,
WRAP NERVE WASTE PER 0.5CM LENGTH,3636752,CDM,278,RC,C9361,HCPCS,Outpatient,,,410,246,,73.8,18,,,percent of total billed charges,pays at 18% of total charges,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,50,,,percent of total billed charges,pays at 50% of total billed charges,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,205,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE 5 X 15 WASTE PER CM LENGTH,3636753,CDM,278,RC,C9353,HCPCS,Outpatient,,,1083,649.8,,194.94,18,,,percent of total billed charges,pays at 18% of total charges,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,758.1,70,,,percent of total billed charges,70% of total billed charges,812.25,75,,,percent of total billed charges,75% of total billed charges,541.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,866.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,649.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,186.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,758.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,649.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,758.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1083,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1083,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.71,1083,
GRAFT NERVE ALLOGRAFT 5 X 30 WST PER CM,3636754,CDM,278,RC,C9353,HCPCS,Outpatient,,,802,481.2,,144.36,18,,,percent of total billed charges,pays at 18% of total charges,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.4,70,,,percent of total billed charges,70% of total billed charges,601.5,75,,,percent of total billed charges,75% of total billed charges,401,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,641.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,561.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,481.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,561.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,802,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,802,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.67,802,
NAIL HUMERAL,3636755,CDM,278,RC,C1713,HCPCS,Outpatient,,,2850,1710,,513,18,,,percent of total billed charges,pays at 18% of total charges,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995,70,,,percent of total billed charges,70% of total billed charges,2137.5,75,,,percent of total billed charges,75% of total billed charges,1425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1710,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,491.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1282.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1995,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1710,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1995,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.6,2850,
SPACER BONE,3636756,CDM,278,RC,,,Outpatient,,,300,180,,54,18,,,percent of total billed charges,pays at 18% of total charges,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,50,,,percent of total billed charges,pays at 50% of total billed charges,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.01,300,
ABUTMENT BAHA,3636757,CDM,278,RC,L8693,HCPCS,Outpatient,,,2500,1500,,6200.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1751.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1751.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1250,50,,,percent of total billed charges,pays at 50% of total billed charges,1750,70,,,percent of total billed charges,70% of total billed charges,1875,75,,,percent of total billed charges,75% of total billed charges,3152.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6130.74,350,,,Fee Schedule,350% of CMS OPPS Rate,1786.67,102,,,Fee Schedule,102% of CMS OPPS Rate,2500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,430.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1125,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1750,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1500,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1751.64,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,950,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1750,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1751.64,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,2500,230,,,Fee Schedule,230% of CMS OPPS Rate,1200,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1751.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1751.64,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,391.75,6200.81,
BONE SUBSTITUTE,3636758,CDM,278,RC,C9359,HCPCS,Outpatient,,,2275,1365,,409.5,18,,,percent of total billed charges,pays at 18% of total charges,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1137.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1592.5,70,,,percent of total billed charges,70% of total billed charges,1706.25,75,,,percent of total billed charges,75% of total billed charges,1137.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1820,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1365,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2275,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,391.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1592.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1365,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,864.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1592.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2275,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,356.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.49,2275,
CANNULA BONE PORT,3636759,CDM,272,RC,,,Outpatient,,,515,309,,92.7,18,,,percent of total billed charges,pays at 18% of total charges,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.5,50,,,percent of total billed charges,pays at 50% of total billed charges,360.5,70,,,percent of total billed charges,70% of total billed charges,386.25,75,,,percent of total billed charges,75% of total billed charges,257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,360.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,463.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.7,515,
KIT KNEE RECONSTRUCT,3636761,CDM,272,RC,,,Outpatient,,,735,441,,132.3,18,,,percent of total billed charges,pays at 18% of total charges,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.5,50,,,percent of total billed charges,pays at 50% of total billed charges,514.5,70,,,percent of total billed charges,70% of total billed charges,551.25,75,,,percent of total billed charges,75% of total billed charges,367.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,562.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,514.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,514.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,735,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,661.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.17,735,
IMPLANT ANKLE TIBIAL,3636762,CDM,278,RC,C1776,HCPCS,Outpatient,,,5750,3450,,1035,18,,,percent of total billed charges,pays at 18% of total charges,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1035,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4025,70,,,percent of total billed charges,70% of total billed charges,4312.5,75,,,percent of total billed charges,75% of total billed charges,2875,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3450,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5750,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,990.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2587.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4025,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3450,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2185,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4025,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2760,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5750,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5750,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,901.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,901.03,5750,
INSERT ANKLE POLY SLIDING CORE,3636763,CDM,278,RC,C1776,HCPCS,Outpatient,,,2025,1215,,364.5,18,,,percent of total billed charges,pays at 18% of total charges,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.5,70,,,percent of total billed charges,70% of total billed charges,1518.75,75,,,percent of total billed charges,75% of total billed charges,1012.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2025,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,348.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1417.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1215,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,769.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1417.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,972,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.32,2025,
IMPLANT ANKLE TALAR,3636764,CDM,278,RC,C1776,HCPCS,Outpatient,,,7591,4554.6,,1366.38,18,,,percent of total billed charges,pays at 18% of total charges,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1366.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5313.7,70,,,percent of total billed charges,70% of total billed charges,5693.25,75,,,percent of total billed charges,75% of total billed charges,3795.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6072.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4554.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7591,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1307.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3415.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5313.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4554.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2884.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5313.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3643.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7591,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7591,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1189.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1189.51,7591,
BLADE RECIPROCATING,3636765,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
BLADE OSCILLATING,3636766,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
SYS PENILE PROSTHESIS,3636768,CDM,278,RC,C1813,HCPCS,Outpatient,,,14300,8580,,2574,18,,,percent of total billed charges,pays at 18% of total charges,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2574,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10010,70,,,percent of total billed charges,70% of total billed charges,10725,75,,,percent of total billed charges,75% of total billed charges,7150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8580,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2463.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6435,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10010,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8580,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5434,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10010,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2240.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240.81,14300,
BAYONET BIPOLAR,3636769,CDM,272,RC,,,Outpatient,,,1050,630,,189,18,,,percent of total billed charges,pays at 18% of total charges,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,525,50,,,percent of total billed charges,pays at 50% of total billed charges,735,70,,,percent of total billed charges,70% of total billed charges,787.5,75,,,percent of total billed charges,75% of total billed charges,525,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,630,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,803.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,735,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,630,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,399,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,735,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1050,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,945,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.54,1050,
PLATE GUIDE NEUTRAL,3636770,CDM,272,RC,,,Outpatient,,,55,33,,9.9,18,,,percent of total billed charges,pays at 18% of total charges,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.5,50,,,percent of total billed charges,pays at 50% of total billed charges,38.5,70,,,percent of total billed charges,70% of total billed charges,41.25,75,,,percent of total billed charges,75% of total billed charges,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,55,
DISCMONITOR,3636771,CDM,272,RC,,,Outpatient,,,520,312,,93.6,18,,,percent of total billed charges,pays at 18% of total charges,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260,50,,,percent of total billed charges,pays at 50% of total billed charges,364,70,,,percent of total billed charges,70% of total billed charges,390,75,,,percent of total billed charges,75% of total billed charges,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,468,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,520,
NUT SCREW,3636772,CDM,278,RC,C1713,HCPCS,Outpatient,,,280,168,,50.4,18,,,percent of total billed charges,pays at 18% of total charges,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,140,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,280,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,280,
LIGHT PIPE,3636773,CDM,272,RC,,,Outpatient,,,500,300,,90,18,,,percent of total billed charges,pays at 18% of total charges,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250,50,,,percent of total billed charges,pays at 50% of total billed charges,350,70,,,percent of total billed charges,70% of total billed charges,375,75,,,percent of total billed charges,75% of total billed charges,250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,382.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,450,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.35,500,
TISSUE GRAFTJACKET PER SQ CM,3636774,CDM,636,RC,Q4107,HCPCS,Outpatient,,,365,219,,65.7,18,,,percent of total billed charges,pays at 18% of total charges,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.5,50,,,percent of total billed charges,pays at 50% of total billed charges,255.5,70,,,percent of total billed charges,70% of total billed charges,273.75,75,,,percent of total billed charges,75% of total billed charges,182.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,365,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,328.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.2,365,
TISSUE GRAFTJACKET PER SQ CM,3636775,CDM,636,RC,Q4107,HCPCS,Outpatient,,,129,77.4,,23.22,18,,,percent of total billed charges,pays at 18% of total charges,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.5,50,,,percent of total billed charges,pays at 50% of total billed charges,90.3,70,,,percent of total billed charges,70% of total billed charges,96.75,75,,,percent of total billed charges,75% of total billed charges,64.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,129,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.21,129,
GRAFTJACKET TISSUE PER SQ CM,3636776,CDM,636,RC,Q4107,HCPCS,Outpatient,,,128,76.8,,23.04,18,,,percent of total billed charges,pays at 18% of total charges,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64,50,,,percent of total billed charges,pays at 50% of total billed charges,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,128,
MAT SUCTION LARGE,3636778,CDM,272,RC,,,Outpatient,,,67.5,40.5,,12.15,18,,,percent of total billed charges,pays at 18% of total charges,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.75,50,,,percent of total billed charges,pays at 50% of total billed charges,47.25,70,,,percent of total billed charges,70% of total billed charges,50.63,75,,,percent of total billed charges,75% of total billed charges,33.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,67.5,
TISSUE CORNEAL FULL THICKNESS,3636779,CDM,278,RC,V2785,HCPCS,Outpatient,,,4225,2535,,3516.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2622.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2622.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2112.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2957.5,70,,,percent of total billed charges,70% of total billed charges,3168.75,75,,,percent of total billed charges,75% of total billed charges,2904.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3380,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3501.99,350,,,Fee Schedule,350% of CMS OPPS Rate,2629.7,103,,,Fee Schedule,103% of CMS OPPS Rate,4225,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,727.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1901.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2957.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2535,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2957.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3079.91,230,,,Fee Schedule,230% of CMS OPPS Rate,2028,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,662.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2622.66,100,,,Fee Schedule,100% of CMS OPPS Rate,662.06,4225,
TISSUE CORNEAL PRECUT,3636780,CDM,278,RC,V2785,HCPCS,Outpatient,,,5460,3276,,4543.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3389.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3389.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2730,50,,,percent of total billed charges,pays at 50% of total billed charges,3822,70,,,percent of total billed charges,70% of total billed charges,4095,75,,,percent of total billed charges,75% of total billed charges,3752.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4525.64,350,,,Fee Schedule,350% of CMS OPPS Rate,3398.38,103,,,Fee Schedule,103% of CMS OPPS Rate,5460,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,940.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2457,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3822,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3276,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2074.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3822,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3980.2,230,,,Fee Schedule,230% of CMS OPPS Rate,2620.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5460,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,855.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.29,100,,,Fee Schedule,100% of CMS OPPS Rate,855.58,5460,
CATH EPIDURAL,3636781,CDM,272,RC,,,Outpatient,,,99,59.4,,,,,,Other,Not Separately reimbursable,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.5,50,,,percent of total billed charges,pays at 50% of total billed charges,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,89.1,
RING MALYGIN,3636782,CDM,272,RC,,,Outpatient,,,188,112.8,,,,,,Other,Not Separately reimbursable,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94,50,,,percent of total billed charges,pays at 50% of total billed charges,131.6,70,,,percent of total billed charges,70% of total billed charges,141,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,169.2,
RING ACETABULAR LCKG,3636783,CDM,278,RC,,,Outpatient,,,650,390,,,,,,Other,Not Separately reimbursable,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325,50,,,percent of total billed charges,pays at 50% of total billed charges,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
POST EXT FIXATOR,3636784,CDM,272,RC,,,Outpatient,,,180,108,,,,,,Other,Not Separately reimbursable,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,50,,,percent of total billed charges,pays at 50% of total billed charges,126,70,,,percent of total billed charges,70% of total billed charges,135,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.21,162,
AMNIOGRAFT LARGE,3636785,CDM,278,RC,V2790,HCPCS,Outpatient,,,1138,682.8,,,,,,Other,Not Separately reimbursable,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569,50,,,percent of total billed charges,pays at 50% of total billed charges,796.6,70,,,percent of total billed charges,70% of total billed charges,853.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,910.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1138,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,196.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,796.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,682.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,432.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,796.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1138,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.32,1138,
HOLDER FIXATOR PLATE,3636786,CDM,272,RC,,,Outpatient,,,450,270,,,,,,Other,Not Separately reimbursable,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,50,,,percent of total billed charges,pays at 50% of total billed charges,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,405,
BLADE TREPHINE,3636787,CDM,272,RC,,,Outpatient,,,116,69.6,,,,,,Other,Not Separately reimbursable,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58,50,,,percent of total billed charges,pays at 50% of total billed charges,81.2,70,,,percent of total billed charges,70% of total billed charges,87,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.18,104.4,
HUMERAL BODY W SCREW,3636788,CDM,278,RC,C1776,HCPCS,Outpatient,,,8515,5109,,,,,,Other,Not Separately reimbursable,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5960.5,70,,,percent of total billed charges,70% of total billed charges,6386.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6812,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8515,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1467.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3831.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5960.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5109,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3235.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5960.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4087.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1334.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1334.3,8515,
STEM MODULAR W SCREWS,3636789,CDM,278,RC,C1776,HCPCS,Outpatient,,,6475,3885,,,,,,Other,Not Separately reimbursable,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4532.5,70,,,percent of total billed charges,70% of total billed charges,4856.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6475,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1115.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2913.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4532.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3885,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2460.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4532.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6475,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1014.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.63,6475,
FLANGE SMALL W SCREWS,3636790,CDM,278,RC,C1776,HCPCS,Outpatient,,,1400,840,,,,,,Other,Not Separately reimbursable,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980,70,,,percent of total billed charges,70% of total billed charges,1050,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,241.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,980,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,532,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,980,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.38,1400,
COMP PATELLAR,3636791,CDM,278,RC,C1776,HCPCS,Outpatient,,,2000,1200,,,,,,Other,Not Separately reimbursable,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,760,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.4,2000,
STEM TIBIAL TOP,3636792,CDM,278,RC,C1776,HCPCS,Outpatient,,,760,456,,,,,,Other,Not Separately reimbursable,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532,70,,,percent of total billed charges,70% of total billed charges,570,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,456,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.09,760,
STEM TIBIAL MID,3636793,CDM,278,RC,C1776,HCPCS,Outpatient,,,760,456,,,,,,Other,Not Separately reimbursable,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532,70,,,percent of total billed charges,70% of total billed charges,570,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,608,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,456,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,288.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,532,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,760,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.09,760,
STEM TALAR,3636794,CDM,278,RC,C1776,HCPCS,Outpatient,,,1660,996,,,,,,Other,Not Separately reimbursable,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162,70,,,percent of total billed charges,70% of total billed charges,1245,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1660,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,286.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1162,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,996,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1162,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1660,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.12,1660,
PROBE VITRECTOMY ANTERIOR,3636795,CDM,272,RC,,,Outpatient,,,215,129,,,,,,Other,Not Separately reimbursable,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.5,50,,,percent of total billed charges,pays at 50% of total billed charges,150.5,70,,,percent of total billed charges,70% of total billed charges,161.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,150.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,150.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.69,193.5,
NEEDLE EPIDURAL,3636796,CDM,272,RC,,,Outpatient,,,130,78,,,,,,Other,Not Separately reimbursable,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65,50,,,percent of total billed charges,pays at 50% of total billed charges,91,70,,,percent of total billed charges,70% of total billed charges,97.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.37,117,
KIT CONTACT LEAD,3636797,CDM,278,RC,C1778,HCPCS,Outpatient,,,2600,1560,,,,,,Other,Not Separately reimbursable,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,70,,,percent of total billed charges,70% of total billed charges,1950,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,447.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,988,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.42,2600,
KIT CONTACT EXTENSION,3636798,CDM,275,RC,C1883,HCPCS,Outpatient,,,1075,645,,,,,,Other,Not Separately reimbursable,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.5,70,,,percent of total billed charges,70% of total billed charges,806.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,185.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,752.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,645,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,752.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,967.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.45,967.5,
KIT TRIAL PRECISION POINT,3636799,CDM,272,RC,,,Outpatient,,,140,84,,,,,,Other,Not Separately reimbursable,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,50,,,percent of total billed charges,pays at 50% of total billed charges,98,70,,,percent of total billed charges,70% of total billed charges,105,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.94,126,
KNEE BUMPER INSERT,3636800,CDM,278,RC,C1776,HCPCS,Outpatient,,,887,532.2,,,,,,Other,Not Separately reimbursable,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.9,70,,,percent of total billed charges,70% of total billed charges,665.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,887,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,152.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,620.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,532.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,620.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,887,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.99,887,
BUSHING FEMORAL,3636801,CDM,278,RC,C1776,HCPCS,Outpatient,,,446,267.6,,,,,,Other,Not Separately reimbursable,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.2,70,,,percent of total billed charges,70% of total billed charges,334.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,312.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,267.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,312.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.89,446,
AXLE,3636802,CDM,278,RC,C1776,HCPCS,Outpatient,,,1480,888,,,,,,Other,Not Separately reimbursable,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1036,70,,,percent of total billed charges,70% of total billed charges,1110,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,255,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1036,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,888,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,562.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1036,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1480,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.92,1480,
TIBIAL SLEEVE,3636803,CDM,278,RC,C1776,HCPCS,Outpatient,,,742,445.2,,,,,,Other,Not Separately reimbursable,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.4,70,,,percent of total billed charges,70% of total billed charges,556.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,593.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,127.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,519.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,445.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,281.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,519.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,742,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.27,742,
TISSUE SCLERA SHELL,3636804,CDM,278,RC,V2627,HCPCS,Outpatient,,,345,207,,5856.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1654.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1654.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.5,50,,,percent of total billed charges,pays at 50% of total billed charges,241.5,70,,,percent of total billed charges,70% of total billed charges,258.75,75,,,percent of total billed charges,75% of total billed charges,2977.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,276,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5790.54,350,,,Fee Schedule,350% of CMS OPPS Rate,1687.53,102,,,Fee Schedule,102% of CMS OPPS Rate,345,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,155.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,241.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1654.44,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,131.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,241.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1654.44,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,345,230,,,Fee Schedule,230% of CMS OPPS Rate,165.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1654.44,100,,,Fee Schedule,100% of CMS OPPS Rate,345,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1654.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,54.06,5856.72,
MESH PHYSIOMESH,3636805,CDM,278,RC,C1781,HCPCS,Outpatient,,,995,597,,,,,,Other,Not Separately reimbursable,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.5,70,,,percent of total billed charges,70% of total billed charges,746.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,796,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,995,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,171.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,696.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,597,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,696.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,995,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.92,995,
COUPLER OFFSET,3636806,CDM,278,RC,,,Outpatient,,,1645,987,,,,,,Other,Not Separately reimbursable,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,822.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1151.5,70,,,percent of total billed charges,70% of total billed charges,1233.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1316,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1645,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1151.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,987,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,625.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1151.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1645,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.77,1645,
SCREW SI,3636807,CDM,278,RC,C1713,HCPCS,Outpatient,,,5720,3432,,,,,,Other,Not Separately reimbursable,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4004,70,,,percent of total billed charges,70% of total billed charges,4290,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4576,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5720,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,985.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2574,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4004,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3432,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2173.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4004,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2745.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5720,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,896.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.32,5720,
CAGE SPINAL,3636808,CDM,278,RC,,,Outpatient,,,8972,5383.2,,,,,,Other,Not Separately reimbursable,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4486,50,,,percent of total billed charges,pays at 50% of total billed charges,6280.4,70,,,percent of total billed charges,70% of total billed charges,6729,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8972,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4037.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6280.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5383.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3409.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6280.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4306.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8972,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1405.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1405.91,8972,
FASCIA LATA SMALL,3636809,CDM,278,RC,C1762,HCPCS,Outpatient,,,473,283.8,,,,,,Other,Not Separately reimbursable,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.1,70,,,percent of total billed charges,70% of total billed charges,354.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.12,473,
PROBE VITRECTOMY,3636810,CDM,272,RC,,,Outpatient,,,305,183,,,,,,Other,Not Separately reimbursable,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.5,50,,,percent of total billed charges,pays at 50% of total billed charges,213.5,70,,,percent of total billed charges,70% of total billed charges,228.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,244,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,213.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,213.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.79,274.5,
FASCIA LATA LG OR XLG,3636811,CDM,278,RC,C1762,HCPCS,Outpatient,,,1608,964.8,,,,,,Other,Not Separately reimbursable,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.6,70,,,percent of total billed charges,70% of total billed charges,1206,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1286.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1608,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,277.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,964.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,611.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1125.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1608,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.97,1608,
INTEGRA WD MATRIX 2X2 WASTE PER SQ CM,3636812,CDM,636,RC,Q4104,HCPCS,Outpatient,,,80,48,,,,,,Other,Not Separately reimbursable,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,72,
INTEGRA WD MATRIX 4X4 WASTE PER SQ CM,3636814,CDM,636,RC,Q4104,HCPCS,Outpatient,,,20,12,,,,,,Other,Not Separately reimbursable,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,18,
MATRIX WOUND 3LAYER PER SQ CM WASTE,3636815,CDM,636,RC,Q4166,HCPCS,Outpatient,,,34.44,20.66,,,,,,Other,Not Separately reimbursable,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.22,50,,,percent of total billed charges,pays at 50% of total billed charges,24.11,70,,,percent of total billed charges,70% of total billed charges,25.83,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,27.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,31,
INTEGRA WD MATRIX 4X10 WASTE PER SQ CM,3636816,CDM,636,RC,Q4104,HCPCS,Outpatient,,,40,24,,,,,,Other,Not Separately reimbursable,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,50,,,percent of total billed charges,pays at 50% of total billed charges,28,70,,,percent of total billed charges,70% of total billed charges,30,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.27,36,
MESH STRATTICE 10 X 10 WASTE PER SQ CM,3636817,CDM,636,RC,Q4130,HCPCS,Outpatient,,,42,25.2,,,,,,Other,Not Separately reimbursable,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,37.8,
MESH STRATTICE 10 X 25 WASTE PER SQ CM,3636818,CDM,636,RC,Q4130,HCPCS,Outpatient,,,42,25.2,,,,,,Other,Not Separately reimbursable,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.58,37.8,
GRAFT NERVE ALLOGRAFT 5 X 50 WST PER CM,3636819,CDM,278,RC,C9353,HCPCS,Outpatient,,,637,382.2,,,,,,Other,Not Separately reimbursable,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.9,70,,,percent of total billed charges,70% of total billed charges,477.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,445.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,445.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.82,637,
TISSUE MEND 5X6 WASTE PER CM,3636820,CDM,636,RC,Q4122,HCPCS,Outpatient,,,205,123,,,,,,Other,Not Separately reimbursable,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,184.5,
TISSUE MEND 6X10 WASTE PER CM,3636821,CDM,636,RC,Q4122,HCPCS,Outpatient,,,205,123,,,,,,Other,Not Separately reimbursable,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.5,50,,,percent of total billed charges,pays at 50% of total billed charges,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,184.5,
GAMMAGRAFT GG225 WASTE PER SQ CM,3636822,CDM,636,RC,Q4111,HCPCS,Outpatient,,,21,12.6,,,,,,Other,Not Separately reimbursable,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,18.9,
WAND COBLATION HIPVAC,3636823,CDM,272,RC,,,Outpatient,,,617.5,370.5,,,,,,Other,Not Separately reimbursable,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.75,50,,,percent of total billed charges,pays at 50% of total billed charges,432.25,70,,,percent of total billed charges,70% of total billed charges,463.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,494,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,432.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,432.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,555.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.76,555.75,
GAMMAGRAFT GG400 WASTE PER SQ CM,3636824,CDM,636,RC,Q4111,HCPCS,Outpatient,,,15,9,,,,,,Other,Not Separately reimbursable,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10.5,70,,,percent of total billed charges,70% of total billed charges,11.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,13.5,
MATRIX WOUND 3LAYER PER SQ CM,3636825,CDM,636,RC,Q4166,HCPCS,Outpatient,,,63.23,37.94,,,,,,Other,Not Separately reimbursable,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.62,50,,,percent of total billed charges,pays at 50% of total billed charges,44.26,70,,,percent of total billed charges,70% of total billed charges,47.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,50.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,56.91,
GAMMAGRAFT GG625 WASTE PER SQ CM,3636826,CDM,636,RC,Q4111,HCPCS,Outpatient,,,9,5.4,,,,,,Other,Not Separately reimbursable,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,50,,,percent of total billed charges,pays at 50% of total billed charges,6.3,70,,,percent of total billed charges,70% of total billed charges,6.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,8.1,
AXLE,3636827,CDM,278,RC,C1776,HCPCS,Outpatient,,,549.9,329.94,,,,,,Other,Not Separately reimbursable,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.93,70,,,percent of total billed charges,70% of total billed charges,412.43,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,439.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,384.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,329.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,384.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.17,549.9,
GRAFT NERVE NEURFLX 2 X 2.5 WST PER CM,3636828,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURFLX 2.5 X 2.5 WST PER CM,3636829,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURFLX 3 X 2.5 WST PER CM,3636830,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURFLX 4 X 2.5 WST PER CM,3636831,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURFLX 5 X 2.5 WST PER CM,3636832,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURFLX 6 X 2.5 WST PER CM,3636833,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURMND 12 X 2.5 WST PER CM,3636834,CDM,278,RC,C9353,HCPCS,Outpatient,,,205,123,,,,,,Other,Not Separately reimbursable,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
GRAFT NERVE NEURMND 12 X 5 WST PER CM,3636835,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURMND 4 X 2.5 WST PER CM,3636836,CDM,278,RC,C9353,HCPCS,Outpatient,,,205,123,,,,,,Other,Not Separately reimbursable,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
GRAFT NERVE NEURMND 4 X 5 WST PER CM,3636837,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
GRAFT NERVE NEURMND 6 X 2.5 WST PER CM,3636838,CDM,278,RC,C9353,HCPCS,Outpatient,,,205,123,,,,,,Other,Not Separately reimbursable,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.5,70,,,percent of total billed charges,70% of total billed charges,153.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.12,205,
GRAFT NERVE NEURMND 6 X 5 WST PER CM,3636839,CDM,278,RC,C9353,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,410,
SYS EUSTACHIAN TUBE BALLOON DILATION,3636840,CDM,272,RC,C1726,HCPCS,Outpatient,,,2613,1567.8,,,,,,Other,Not Separately reimbursable,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1829.1,70,,,percent of total billed charges,70% of total billed charges,1959.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1998.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,450.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1829.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1567.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1829.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2351.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.46,2351.7,
CATH SINUS BALLOON,3636841,CDM,272,RC,,,Outpatient,,,2613,1567.8,,,,,,Other,Not Separately reimbursable,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1306.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1829.1,70,,,percent of total billed charges,70% of total billed charges,1959.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1998.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1829.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1567.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1829.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2351.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.46,2351.7,
CATH SINUS BALLOON W GUIDE,3636842,CDM,272,RC,,,Outpatient,,,3040.7,1824.42,,,,,,Other,Not Separately reimbursable,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1520.35,50,,,percent of total billed charges,pays at 50% of total billed charges,2128.49,70,,,percent of total billed charges,70% of total billed charges,2280.53,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2432.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2326.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2128.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1824.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1155.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2128.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1459.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2736.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.48,2736.63,
MICROMATRIX PARTICLES PER MG 1000MG,3636843,CDM,636,RC,Q4118,HCPCS,Outpatient,,,2.88,1.73,,,,,,Other,Not Separately reimbursable,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,50,,,percent of total billed charges,pays at 50% of total billed charges,2.02,70,,,percent of total billed charges,70% of total billed charges,2.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,2.59,
MICROMATRIX PARTICLES PER MG 500MG,3636844,CDM,636,RC,Q4118,HCPCS,Outpatient,,,3.41,2.05,,,,,,Other,Not Separately reimbursable,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,50,,,percent of total billed charges,pays at 50% of total billed charges,2.39,70,,,percent of total billed charges,70% of total billed charges,2.56,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.53,3.07,
MICROMATRIX PARTICLES PER MG 200MG,3636845,CDM,636,RC,Q4118,HCPCS,Outpatient,,,3.7,2.22,,,,,,Other,Not Separately reimbursable,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.85,50,,,percent of total billed charges,pays at 50% of total billed charges,2.59,70,,,percent of total billed charges,70% of total billed charges,2.78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.58,3.33,
BURN MATRIX PER SQ CM,3636846,CDM,636,RC,Q4166,HCPCS,Outpatient,,,39.34,23.6,,,,,,Other,Not Separately reimbursable,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.67,50,,,percent of total billed charges,pays at 50% of total billed charges,27.54,70,,,percent of total billed charges,70% of total billed charges,29.51,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,31.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.16,35.41,
MATRIX WOUND 1 LAYER PER SQ CM,3636847,CDM,636,RC,Q4166,HCPCS,Outpatient,,,15.58,9.35,,,,,,Other,Not Separately reimbursable,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,50,,,percent of total billed charges,pays at 50% of total billed charges,10.91,70,,,percent of total billed charges,70% of total billed charges,11.69,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.44,14.02,
MATRIX WOUND 1 LAYER PER SQ CM,3636848,CDM,636,RC,Q4166,HCPCS,Outpatient,,,6.1,3.66,,,,,,Other,Not Separately reimbursable,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,50,,,percent of total billed charges,pays at 50% of total billed charges,4.27,70,,,percent of total billed charges,70% of total billed charges,4.58,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,5.49,
BUSHING FEMORAL,3636849,CDM,278,RC,C1776,HCPCS,Outpatient,,,507,304.2,,,,,,Other,Not Separately reimbursable,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.9,70,,,percent of total billed charges,70% of total billed charges,380.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.45,507,
IMPLANT METATARSAL,3636850,CDM,278,RC,C1776,HCPCS,Outpatient,,,5239,3143.4,,,,,,Other,Not Separately reimbursable,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3667.3,70,,,percent of total billed charges,70% of total billed charges,3929.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5239,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,902.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2357.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3667.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1990.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3667.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2514.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5239,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.95,5239,
FIXATOR DISTAL RADIUS,3636851,CDM,278,RC,C1713,HCPCS,Outpatient,,,3352.26,2011.36,,,,,,Other,Not Separately reimbursable,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2346.58,70,,,percent of total billed charges,70% of total billed charges,2514.2,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2681.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3352.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,577.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1508.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2346.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2011.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1273.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2346.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1609.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3352.26,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.3,3352.26,
SYS AC JOINT RECONSTRUCT ZIPTIGHT,3636852,CDM,278,RC,C1713,HCPCS,Outpatient,,,838.5,503.1,,,,,,Other,Not Separately reimbursable,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.95,70,,,percent of total billed charges,70% of total billed charges,628.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,670.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,586.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,586.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,838.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,838.5,
GRAFT NERVE CONNECT 2X15 PER SQCM,3636853,CDM,278,RC,C9353,HCPCS,Outpatient,,,80,48,,,,,,Other,Not Separately reimbursable,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
GRAFT NERVE CONNECT 2X15 PER SQCM WASTE,3636854,CDM,278,RC,C9353,HCPCS,Outpatient,,,80,48,,,,,,Other,Not Separately reimbursable,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
GRAFT NERVE CONNECT 3X15 PER SQCM,3636855,CDM,278,RC,C9353,HCPCS,Outpatient,,,80,48,,,,,,Other,Not Separately reimbursable,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
GRAFT NERVE CONNECT 3X15 PER SQCM WASTE,3636856,CDM,278,RC,C9353,HCPCS,Outpatient,,,80,48,,,,,,Other,Not Separately reimbursable,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
MATRIX COLLAGEN PER SQ CM,3636857,CDM,278,RC,C9358,HCPCS,Outpatient,,,10.4,6.24,,,,,,Other,Not Separately reimbursable,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.2,50,,,percent of total billed charges,pays at 50% of total billed charges,7.28,70,,,percent of total billed charges,70% of total billed charges,7.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,10.4,
MATRIX COLLAGEN WASTE PER SQ CM,3636858,CDM,278,RC,C9358,HCPCS,Outpatient,,,10.4,6.24,,,,,,Other,Not Separately reimbursable,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.2,50,,,percent of total billed charges,pays at 50% of total billed charges,7.28,70,,,percent of total billed charges,70% of total billed charges,7.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.63,10.4,
ANCHOR SUTURE,3636859,CDM,278,RC,C1713,HCPCS,Outpatient,,,1243.8,746.28,,,,,,Other,Not Separately reimbursable,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,870.66,70,,,percent of total billed charges,70% of total billed charges,932.85,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,995.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1243.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,214.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,870.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,746.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,472.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,870.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1243.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,194.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.9,1243.8,
SCREW SI LOK,3636860,CDM,278,RC,C1713,HCPCS,Outpatient,,,3250,1950,,,,,,Other,Not Separately reimbursable,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,70,,,percent of total billed charges,70% of total billed charges,2437.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,559.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.28,3250,
TRAY TIBIAL,3636861,CDM,278,RC,C1776,HCPCS,Outpatient,,,14080.3,8448.18,,,,,,Other,Not Separately reimbursable,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9856.21,70,,,percent of total billed charges,70% of total billed charges,10560.23,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,11264.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14080.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2426.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6336.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9856.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8448.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5350.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9856.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6758.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14080.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2206.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2206.38,14080.3,
IMPLANT ANKLE TALAR DOME,3636862,CDM,278,RC,C1776,HCPCS,Outpatient,,,14983.3,8989.98,,,,,,Other,Not Separately reimbursable,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10488.31,70,,,percent of total billed charges,70% of total billed charges,11237.48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,11986.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14983.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2581.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6742.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10488.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8989.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5693.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10488.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7191.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14983.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2347.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2347.88,14983.3,
GUIDE ORTHO RESECTION,3636863,CDM,272,RC,,,Outpatient,,,2731.3,1638.78,,,,,,Other,Not Separately reimbursable,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365.65,50,,,percent of total billed charges,pays at 50% of total billed charges,1911.91,70,,,percent of total billed charges,70% of total billed charges,2048.48,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2185.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2089.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1229.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1911.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1638.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1037.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1911.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1311.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2458.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,427.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.99,2458.17,
IMPLANT TALAR POLY INSERT,3636864,CDM,278,RC,C1776,HCPCS,Outpatient,,,4932.2,2959.32,,,,,,Other,Not Separately reimbursable,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3452.54,70,,,percent of total billed charges,70% of total billed charges,3699.15,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3945.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4932.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,849.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2219.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3452.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2959.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1874.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3452.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4932.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,772.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.88,4932.2,
SYS PROSTATIC URETHRAL LIFT,3636865,CDM,278,RC,L8699,HCPCS,Outpatient,,,1267.5,760.5,,,,,,Other,Not Separately reimbursable,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.75,50,,,percent of total billed charges,pays at 50% of total billed charges,887.25,70,,,percent of total billed charges,70% of total billed charges,950.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1014,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1267.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,218.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,887.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,760.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,481.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,887.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1267.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.62,1267.5,
CYROANALGESIA TIP,3636868,CDM,272,RC,,,Outpatient,,,740,444,,,,,,Other,Not Separately reimbursable,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370,50,,,percent of total billed charges,pays at 50% of total billed charges,518,70,,,percent of total billed charges,70% of total billed charges,555,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,566.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,518,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,444,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,281.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,518,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.96,666,
KIT PERFLUORON,3636869,CDM,272,RC,,,Outpatient,,,598,358.8,,,,,,Other,Not Separately reimbursable,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299,50,,,percent of total billed charges,pays at 50% of total billed charges,418.6,70,,,percent of total billed charges,70% of total billed charges,448.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,478.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,418.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,418.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,538.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.71,538.2,
GUIDE RESECTION ORTHO,3636890,CDM,272,RC,,,Outpatient,,,1830.4,1098.24,,,,,,Other,Not Separately reimbursable,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.2,50,,,percent of total billed charges,pays at 50% of total billed charges,1281.28,70,,,percent of total billed charges,70% of total billed charges,1372.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1464.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1281.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1098.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,695.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1281.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1647.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.82,1647.36,
SYS PANNUS RETENTION STRAP,3636891,CDM,272,RC,,,Outpatient,,,99.75,59.85,,,,,,Other,Not Separately reimbursable,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.88,50,,,percent of total billed charges,pays at 50% of total billed charges,69.83,70,,,percent of total billed charges,70% of total billed charges,74.81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,79.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,69.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.63,89.78,
SCOPE AMBU DISP,3636892,CDM,272,RC,,,Outpatient,,,409.5,245.7,,,,,,Other,Not Separately reimbursable,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,50,,,percent of total billed charges,pays at 50% of total billed charges,286.65,70,,,percent of total billed charges,70% of total billed charges,307.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,327.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,286.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.17,368.55,
SYS IMP SPEEDBRIDGE W/BIO SWIVIELOCK,3636893,CDM,278,RC,C1776,HCPCS,Outpatient,,,3994,2396.4,,,,,,Other,Not Separately reimbursable,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2795.8,70,,,percent of total billed charges,70% of total billed charges,2995.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3994,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,688.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2795.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2396.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1517.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2795.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1917.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3994,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,625.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.86,3994,
SPACER VERTEBRAE,3636894,CDM,278,RC,C1821,HCPCS,Outpatient,,,16445,9867,,,,,,Other,Not Separately reimbursable,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11511.5,70,,,percent of total billed charges,70% of total billed charges,12333.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,13156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16445,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2833.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7400.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11511.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9867,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6249.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11511.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7893.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16445,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2576.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2576.93,16445,
INSTRUMENTS HIP DISP,3636895,CDM,272,RC,,,Outpatient,,,2343.9,1406.34,,,,,,Other,Not Separately reimbursable,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1171.95,50,,,percent of total billed charges,pays at 50% of total billed charges,1640.73,70,,,percent of total billed charges,70% of total billed charges,1757.93,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1875.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1793.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1054.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1640.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1406.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,890.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1640.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2109.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.29,2109.51,
TIBIAL BEARING,3636896,CDM,278,RC,C1776,HCPCS,Outpatient,,,1132.3,679.38,,,,,,Other,Not Separately reimbursable,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,792.61,70,,,percent of total billed charges,70% of total billed charges,849.23,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,905.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1132.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,195.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,792.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,679.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,430.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,792.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1132.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.43,1132.3,
COLLAGEN GRAFT NERVE WASTE PER CM,3636897,CDM,278,RC,C9353,HCPCS,Outpatient,,,637,382.2,,,,,,Other,Not Separately reimbursable,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.9,70,,,percent of total billed charges,70% of total billed charges,477.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,509.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,445.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,445.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.82,637,
COLLAGEN GRAFT NERVE PER CM,3636898,CDM,278,RC,C9353,HCPCS,Outpatient,,,511,306.6,,,,,,Other,Not Separately reimbursable,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.7,70,,,percent of total billed charges,70% of total billed charges,383.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,408.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,511,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.07,511,
COLLAGEN GRAFT NERVE WASTE PER CM,3636899,CDM,278,RC,C9353,HCPCS,Outpatient,,,511,306.6,,,,,,Other,Not Separately reimbursable,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.7,70,,,percent of total billed charges,70% of total billed charges,383.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,408.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,357.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,511,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.07,511,
COLLAGEN GRAFT NERVE PER CM,3636900,CDM,278,RC,C9353,HCPCS,Outpatient,,,390,234,,,,,,Other,Not Separately reimbursable,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273,70,,,percent of total billed charges,70% of total billed charges,292.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.11,390,
COLLAGEN GRAFT NERVE WASTE PER CM,3636901,CDM,278,RC,C9353,HCPCS,Outpatient,,,390,234,,,,,,Other,Not Separately reimbursable,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273,70,,,percent of total billed charges,70% of total billed charges,292.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,312,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,273,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.11,390,
COLLAGEN GRAFT NERVE PER CM,3636902,CDM,278,RC,C9353,HCPCS,Outpatient,,,340,204,,,,,,Other,Not Separately reimbursable,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
COLLAGEN GRAFT NERVE WASTE PER CM,3636903,CDM,278,RC,C9353,HCPCS,Outpatient,,,340,204,,,,,,Other,Not Separately reimbursable,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
COLLAGEN GRAFT NERVE PER CM,3636904,CDM,278,RC,C9353,HCPCS,Outpatient,,,274,164.4,,,,,,Other,Not Separately reimbursable,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.8,70,,,percent of total billed charges,70% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,274,
COLLAGEN GRAFT NERVE WASTE PER CM,3636905,CDM,278,RC,C9353,HCPCS,Outpatient,,,274,164.4,,,,,,Other,Not Separately reimbursable,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.8,70,,,percent of total billed charges,70% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,274,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,274,
COLLAGEN GRAFT NERVE PER CM,3636906,CDM,278,RC,C9353,HCPCS,Outpatient,,,219,131.4,,,,,,Other,Not Separately reimbursable,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.3,70,,,percent of total billed charges,70% of total billed charges,164.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,219,
COLLAGEN GRAFT NERVE WASTE PER CM,3636907,CDM,278,RC,C9353,HCPCS,Outpatient,,,219,131.4,,,,,,Other,Not Separately reimbursable,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.3,70,,,percent of total billed charges,70% of total billed charges,164.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,175.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,219,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,219,
NEEDLE ABLATION,3636908,CDM,272,RC,,,Outpatient,,,2463.5,1478.1,,,,,,Other,Not Separately reimbursable,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1231.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1724.45,70,,,percent of total billed charges,70% of total billed charges,1847.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1970.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1884.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1724.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1478.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1724.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1182.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2217.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.03,2217.15,
CATH INTRATHECAL,3636909,CDM,278,RC,C1755,HCPCS,Outpatient,,,1303,781.8,,,,,,Other,Not Separately reimbursable,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,912.1,70,,,percent of total billed charges,70% of total billed charges,977.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1042.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1303,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,224.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,586.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,912.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,781.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,495.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,912.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1303,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.18,1303,
KIT ACCESSORY,3636910,CDM,278,RC,,,Outpatient,,,317,190.2,,,,,,Other,Not Separately reimbursable,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
KIT VENTRICULAR,3639784,CDM,272,RC,,,Outpatient,,,481,288.6,,,,,,Other,Not Separately reimbursable,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.5,50,,,percent of total billed charges,pays at 50% of total billed charges,336.7,70,,,percent of total billed charges,70% of total billed charges,360.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,432.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.37,432.9,
KIT EXT DRAINAGE,3639785,CDM,272,RC,,,Outpatient,,,470.5,282.3,,,,,,Other,Not Separately reimbursable,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.25,50,,,percent of total billed charges,pays at 50% of total billed charges,329.35,70,,,percent of total billed charges,70% of total billed charges,352.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,376.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,329.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,282.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,329.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.73,423.45,
COUNTERSINK,3639800,CDM,272,RC,,,Outpatient,,,412,247.2,,,,,,Other,Not Separately reimbursable,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206,50,,,percent of total billed charges,pays at 50% of total billed charges,288.4,70,,,percent of total billed charges,70% of total billed charges,309,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,329.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,288.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,288.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,370.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.56,370.8,
WEDGE ORTHO  FOOT,3639801,CDM,278,RC,C1776,HCPCS,Outpatient,,,4077,2446.2,,,,,,Other,Not Separately reimbursable,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2853.9,70,,,percent of total billed charges,70% of total billed charges,3057.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,3261.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4077,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,702.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1834.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2853.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2446.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1549.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2853.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1956.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4077,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,638.87,4077,
CROUCH CORNEAL PROTECTOR,3639812,CDM,272,RC,,,Outpatient,,,49.5,29.7,,,,,,Other,Not Separately reimbursable,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,44.55,
IMPLANT INTERPHALANGEAL FUSION,3639813,CDM,278,RC,C1713,HCPCS,Outpatient,,,1582.1,949.26,,,,,,Other,Not Separately reimbursable,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1107.47,70,,,percent of total billed charges,70% of total billed charges,1186.58,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1265.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1582.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,272.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1107.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,949.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,601.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1107.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1582.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.92,1582.1,
IMPLANT KERATOPROSTHESIS,3639814,CDM,278,RC,C1818,HCPCS,Outpatient,,,7800,4680,,,,,,Other,Not Separately reimbursable,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5460,70,,,percent of total billed charges,70% of total billed charges,5850,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1343.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3510,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2964,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.26,7800,
KIT SCHLEIN POSITIONER PT,3639820,CDM,272,RC,,,Outpatient,,,194.5,116.7,,,,,,Other,Not Separately reimbursable,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.25,50,,,percent of total billed charges,pays at 50% of total billed charges,136.15,70,,,percent of total billed charges,70% of total billed charges,145.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,155.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,136.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,136.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.48,175.05,
CONNECTOR RT ANGLE,3639823,CDM,278,RC,,,Outpatient,,,98.5,59.1,,,,,,Other,Not Separately reimbursable,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.25,50,,,percent of total billed charges,pays at 50% of total billed charges,68.95,70,,,percent of total billed charges,70% of total billed charges,73.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,78.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.43,98.5,
PERI-STRIPS GIA ENDO 60,3639825,CDM,272,RC,,,Outpatient,,,1838.5,1103.1,,,,,,Other,Not Separately reimbursable,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1286.95,70,,,percent of total billed charges,70% of total billed charges,1378.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1470.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1406.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1286.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1103.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1286.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1654.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.09,1654.65,
PLATE DCP 2H TO 5H,3639838,CDM,278,RC,C1713,HCPCS,Outpatient,,,236.5,141.9,,,,,,Other,Not Separately reimbursable,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.55,70,,,percent of total billed charges,70% of total billed charges,177.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,189.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,165.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,165.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.06,236.5,
PLATE T SM,3639839,CDM,278,RC,,,Outpatient,,,101,60.6,,,,,,Other,Not Separately reimbursable,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.5,50,,,percent of total billed charges,pays at 50% of total billed charges,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.83,101,
BAR LOCKING TIBIAL,3639845,CDM,278,RC,,,Outpatient,,,355,213,,,,,,Other,Not Separately reimbursable,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,50,,,percent of total billed charges,pays at 50% of total billed charges,248.5,70,,,percent of total billed charges,70% of total billed charges,266.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,248.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,248.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,355,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.63,355,
TALC STRL,3639859,CDM,272,RC,,,Outpatient,,,184,110.4,,,,,,Other,Not Separately reimbursable,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,165.6,
BLADE FULL RADIUS,3639864,CDM,272,RC,,,Outpatient,,,206,123.6,,,,,,Other,Not Separately reimbursable,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103,50,,,percent of total billed charges,pays at 50% of total billed charges,144.2,70,,,percent of total billed charges,70% of total billed charges,154.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,185.4,
BLADE TURBOWHISKER,3639867,CDM,272,RC,,,Outpatient,,,206,123.6,,,,,,Other,Not Separately reimbursable,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103,50,,,percent of total billed charges,pays at 50% of total billed charges,144.2,70,,,percent of total billed charges,70% of total billed charges,154.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,185.4,
PLATE WRIST FUSION,3639868,CDM,278,RC,C1713,HCPCS,Outpatient,,,2218.5,1331.1,,,,,,Other,Not Separately reimbursable,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1552.95,70,,,percent of total billed charges,70% of total billed charges,1663.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1774.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2218.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,382.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,998.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1552.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1331.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1552.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2218.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.64,2218.5,
ESMARK,3639870,CDM,272,RC,,,Outpatient,,,55.5,33.3,,,,,,Other,Not Separately reimbursable,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.75,50,,,percent of total billed charges,pays at 50% of total billed charges,38.85,70,,,percent of total billed charges,70% of total billed charges,41.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,44.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.7,49.95,
POPE OTO WICK MEROCEL,3639900,CDM,272,RC,,,Outpatient,,,8.5,5.1,,,,,,Other,Not Separately reimbursable,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,50,,,percent of total billed charges,pays at 50% of total billed charges,5.95,70,,,percent of total billed charges,70% of total billed charges,6.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,6.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,7.65,
CRAWFORD LAC INTUBATION,3639904,CDM,272,RC,,,Outpatient,,,169,101.4,,,,,,Other,Not Separately reimbursable,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.5,50,,,percent of total billed charges,pays at 50% of total billed charges,118.3,70,,,percent of total billed charges,70% of total billed charges,126.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,152.1,
KIT APPLIED ACI-ACL,3639910,CDM,272,RC,,,Outpatient,,,2852,1711.2,,,,,,Other,Not Separately reimbursable,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1426,50,,,percent of total billed charges,pays at 50% of total billed charges,1996.4,70,,,percent of total billed charges,70% of total billed charges,2139,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2281.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2181.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1283.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1996.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1711.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1996.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2566.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.91,2566.8,
TUBING INSUFFLATION,3639922,CDM,272,RC,,,Outpatient,,,53.5,32.1,,,,,,Other,Not Separately reimbursable,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,48.15,
SCREW CORTEX TI 2.7,3639933,CDM,278,RC,C1713,HCPCS,Outpatient,,,89.5,53.7,,,,,,Other,Not Separately reimbursable,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
DRILL BIT 1.8,3639934,CDM,272,RC,,,Outpatient,,,248,148.8,,,,,,Other,Not Separately reimbursable,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124,50,,,percent of total billed charges,pays at 50% of total billed charges,173.6,70,,,percent of total billed charges,70% of total billed charges,186,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,223.2,
MESH TRELEX 1 X 4,3639936,CDM,278,RC,C1781,HCPCS,Outpatient,,,177.5,106.5,,,,,,Other,Not Separately reimbursable,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.25,70,,,percent of total billed charges,70% of total billed charges,133.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,142,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,177.5,
SHEARS HARMONIC HD,3639937,CDM,272,RC,,,Outpatient,,,1740.79,1044.47,,,,,,Other,Not Separately reimbursable,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,870.4,50,,,percent of total billed charges,pays at 50% of total billed charges,1218.55,70,,,percent of total billed charges,70% of total billed charges,1305.59,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1392.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1331.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1218.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1044.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,661.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1218.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1566.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,272.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.78,1566.71,
CABLE BONE PLATE,3639950,CDM,278,RC,,,Outpatient,,,448.5,269.1,,,,,,Other,Not Separately reimbursable,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.25,50,,,percent of total billed charges,pays at 50% of total billed charges,313.95,70,,,percent of total billed charges,70% of total billed charges,336.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,358.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,313.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,448.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,448.5,
DEVICE VENTRICULAR,3639951,CDM,272,RC,,,Outpatient,,,629,377.4,,,,,,Other,Not Separately reimbursable,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.5,50,,,percent of total billed charges,pays at 50% of total billed charges,440.3,70,,,percent of total billed charges,70% of total billed charges,471.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,503.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,440.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,440.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,566.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.56,566.1,
GUIDE PIN,3639954,CDM,272,RC,,,Outpatient,,,127,76.2,,,,,,Other,Not Separately reimbursable,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,50,,,percent of total billed charges,pays at 50% of total billed charges,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.9,114.3,
PUNCH AORTIC 4.0,3639966,CDM,272,RC,,,Outpatient,,,110.5,66.3,,,,,,Other,Not Separately reimbursable,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.25,50,,,percent of total billed charges,pays at 50% of total billed charges,77.35,70,,,percent of total billed charges,70% of total billed charges,82.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,88.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,77.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.32,99.45,
KIT TRANSTIBIAL,3639970,CDM,272,RC,,,Outpatient,,,518.5,311.1,,,,,,Other,Not Separately reimbursable,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.25,50,,,percent of total billed charges,pays at 50% of total billed charges,362.95,70,,,percent of total billed charges,70% of total billed charges,388.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,414.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,362.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,466.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.25,466.65,
TUBING MALIS BIPOLAR IRRIG,3639973,CDM,272,RC,,,Outpatient,,,117.5,70.5,,,,,,Other,Not Separately reimbursable,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.75,50,,,percent of total billed charges,pays at 50% of total billed charges,82.25,70,,,percent of total billed charges,70% of total billed charges,88.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.41,105.75,
REAMER SHAFT FLEXIBLE,3639975,CDM,272,RC,,,Outpatient,,,978,586.8,,,,,,Other,Not Separately reimbursable,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489,50,,,percent of total billed charges,pays at 50% of total billed charges,684.6,70,,,percent of total billed charges,70% of total billed charges,733.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,782.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,684.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,586.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,371.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,684.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,880.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.25,880.2,
REAMING ROD,3639976,CDM,272,RC,,,Outpatient,,,197.5,118.5,,,,,,Other,Not Separately reimbursable,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.75,50,,,percent of total billed charges,pays at 50% of total billed charges,138.25,70,,,percent of total billed charges,70% of total billed charges,148.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,158,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.95,177.75,
PLATE T LCP TI 2.7,3639986,CDM,278,RC,C1713,HCPCS,Outpatient,,,1130,678,,,,,,Other,Not Separately reimbursable,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,791,70,,,percent of total billed charges,70% of total billed charges,847.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,194.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,791,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,791,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1130,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.07,1130,
IMPLANT OCULAR,3639990,CDM,278,RC,C1783,HCPCS,Outpatient,,,104,62.4,,,,,,Other,Not Separately reimbursable,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,104,
PLATE T LCP TI 2.7,3639991,CDM,278,RC,C1713,HCPCS,Outpatient,,,1130,678,,,,,,Other,Not Separately reimbursable,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,791,70,,,percent of total billed charges,70% of total billed charges,847.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,904,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,194.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,791,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,429.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,791,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1130,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.07,1130,
SCREW CORTEX 4.5,3639992,CDM,278,RC,C1713,HCPCS,Outpatient,,,48.5,29.1,,,,,,Other,Not Separately reimbursable,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
SET RADIAL ARTERY CATH,3640001,CDM,272,RC,,,Outpatient,,,35.5,21.3,,,,,,Other,Not Separately reimbursable,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,50,,,percent of total billed charges,pays at 50% of total billed charges,24.85,70,,,percent of total billed charges,70% of total billed charges,26.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.56,31.95,
STOPCOCK 4 WAY,3640001,CDM,272,RC,,,Outpatient,,,9.5,5.7,,,,,,Other,Not Separately reimbursable,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,8.55,
DRESSING TRANSPARENT,3640001,CDM,272,RC,,,Outpatient,,,1,0.6,,,,,,Other,Not Separately reimbursable,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,0.9,
TUBING INSUFFLATION,3640001,CDM,272,RC,,,Outpatient,,,53.5,32.1,,,,,,Other,Not Separately reimbursable,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,48.15,
AMBU BAG,3640001,CDM,272,RC,,,Outpatient,,,68.5,41.1,,,,,,Other,Not Separately reimbursable,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,61.65,
BAG PRESSURE SM-MED,3640001,CDM,272,RC,,,Outpatient,,,43,25.8,,,,,,Other,Not Separately reimbursable,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.5,50,,,percent of total billed charges,pays at 50% of total billed charges,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,38.7,
LOOPS VESSEL,3640001,CDM,272,RC,,,Outpatient,,,9.5,5.7,,,,,,Other,Not Separately reimbursable,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,8.55,
DERMABOND ADHESIVE,3640001,CDM,272,RC,,,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,74.7,
PACK OPEN HEART #1,3640001,CDM,272,RC,,,Outpatient,,,887,532.2,,,,,,Other,Not Separately reimbursable,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.5,50,,,percent of total billed charges,pays at 50% of total billed charges,620.9,70,,,percent of total billed charges,70% of total billed charges,665.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,709.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,620.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,532.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,620.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,798.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.99,798.3,
LENS FOG RED DEV,3640001,CDM,272,RC,,,Outpatient,,,24,14.4,,,,,,Other,Not Separately reimbursable,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,21.6,
METER URINE,3640001,CDM,272,RC,,,Outpatient,,,39,23.4,,,,,,Other,Not Separately reimbursable,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,35.1,
BLADE BEAVER MINI,3640001,CDM,272,RC,,,Outpatient,,,41,24.6,,,,,,Other,Not Separately reimbursable,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,36.9,
WRIST SUPPORT ART LINE,3640001,CDM,272,RC,,,Outpatient,,,28.5,17.1,,,,,,Other,Not Separately reimbursable,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.25,50,,,percent of total billed charges,pays at 50% of total billed charges,19.95,70,,,percent of total billed charges,70% of total billed charges,21.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,22.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,25.65,
DSG AQUACEL FOAM,3640001,CDM,272,RC,,,Outpatient,,,11,6.6,,,,,,Other,Not Separately reimbursable,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.5,50,,,percent of total billed charges,pays at 50% of total billed charges,7.7,70,,,percent of total billed charges,70% of total billed charges,8.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,9.9,
KIT BIOPATCH DRESSING,3640001,CDM,272,RC,A6257,HCPCS,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
CATH THORACIC,3640001,CDM,272,RC,,,Outpatient,,,71,42.6,,12.78,18,,,percent of total billed charges,pays at 18% of total charges,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.5,50,,,percent of total billed charges,pays at 50% of total billed charges,49.7,70,,,percent of total billed charges,70% of total billed charges,53.25,75,,,percent of total billed charges,75% of total billed charges,35.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,71,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,63.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.13,71,
PACK MAJOR GENERAL,3640002,CDM,272,RC,,,Outpatient,,,200.5,120.3,,36.09,18,,,percent of total billed charges,pays at 18% of total charges,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.25,50,,,percent of total billed charges,pays at 50% of total billed charges,140.35,70,,,percent of total billed charges,70% of total billed charges,150.38,75,,,percent of total billed charges,75% of total billed charges,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,200.5,
DRESSING-SURGICEL 4 X 8,3640002,CDM,272,RC,,,Outpatient,,,115.5,69.3,,20.79,18,,,percent of total billed charges,pays at 18% of total charges,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,50,,,percent of total billed charges,pays at 50% of total billed charges,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,57.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,115.5,
PAD GROUNDING,3640002,CDM,272,RC,,,Outpatient,,,19,11.4,,3.42,18,,,percent of total billed charges,pays at 18% of total charges,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,19,
SUCTION IRRIGATOR,3640002,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
DERMABOND ADHESIVE,3640002,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
TROCAR 5MM,3640002,CDM,272,RC,,,Outpatient,,,314,188.4,,56.52,18,,,percent of total billed charges,pays at 18% of total charges,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157,50,,,percent of total billed charges,pays at 50% of total billed charges,219.8,70,,,percent of total billed charges,70% of total billed charges,235.5,75,,,percent of total billed charges,75% of total billed charges,157,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,251.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,219.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,219.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,314,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,282.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.2,314,
LAP TROCAR ENDOPATH 12MM,3640002,CDM,272,RC,,,Outpatient,,,278.5,167.1,,50.13,18,,,percent of total billed charges,pays at 18% of total charges,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.25,50,,,percent of total billed charges,pays at 50% of total billed charges,194.95,70,,,percent of total billed charges,70% of total billed charges,208.88,75,,,percent of total billed charges,75% of total billed charges,139.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,278.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,250.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.64,278.5,
KITTNER ENDOSCOPIC,3640002,CDM,272,RC,,,Outpatient,,,120,72,,21.6,18,,,percent of total billed charges,pays at 18% of total charges,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60,50,,,percent of total billed charges,pays at 50% of total billed charges,84,70,,,percent of total billed charges,70% of total billed charges,90,75,,,percent of total billed charges,75% of total billed charges,60,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,120,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,108,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.8,120,
NEEDLE INSUFFLATION,3640002,CDM,272,RC,,,Outpatient,,,108,64.8,,19.44,18,,,percent of total billed charges,pays at 18% of total charges,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,50,,,percent of total billed charges,pays at 50% of total billed charges,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,108,
SET SMOKE EVAC INSUFFLATION,3640002,CDM,272,RC,,,Outpatient,,,173.25,103.95,,31.19,18,,,percent of total billed charges,pays at 18% of total charges,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.63,50,,,percent of total billed charges,pays at 50% of total billed charges,121.28,70,,,percent of total billed charges,70% of total billed charges,129.94,75,,,percent of total billed charges,75% of total billed charges,86.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,173.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,173.25,
HEMOCLIP ALL SIZES,3640002,CDM,272,RC,,,Outpatient,,,98,58.8,,17.64,18,,,percent of total billed charges,pays at 18% of total charges,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49,50,,,percent of total billed charges,pays at 50% of total billed charges,68.6,70,,,percent of total billed charges,70% of total billed charges,73.5,75,,,percent of total billed charges,75% of total billed charges,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,98,
TRAY CATH W/FOLEY,3640014,CDM,272,RC,,,Outpatient,,,133.5,80.1,,24.03,18,,,percent of total billed charges,pays at 18% of total charges,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.75,50,,,percent of total billed charges,pays at 50% of total billed charges,93.45,70,,,percent of total billed charges,70% of total billed charges,100.13,75,,,percent of total billed charges,75% of total billed charges,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,133.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,133.5,
SUCTION IRRIGATOR,3640014,CDM,272,RC,,,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.73,228,
PACK TOTAL HIP,3640014,CDM,272,RC,,,Outpatient,,,354,212.4,,63.72,18,,,percent of total billed charges,pays at 18% of total charges,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177,50,,,percent of total billed charges,pays at 50% of total billed charges,247.8,70,,,percent of total billed charges,70% of total billed charges,265.5,75,,,percent of total billed charges,75% of total billed charges,177,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,283.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,247.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,354,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,318.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.47,354,
BLADE SAW,3640014,CDM,272,RC,,,Outpatient,,,128,76.8,,23.04,18,,,percent of total billed charges,pays at 18% of total charges,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64,50,,,percent of total billed charges,pays at 50% of total billed charges,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,128,
HEMOVAC MED,3640014,CDM,272,RC,C1729,HCPCS,Outpatient,,,89.5,53.7,,16.11,18,,,percent of total billed charges,pays at 18% of total charges,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,44.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
HOODS DISP ORTHO,3640014,CDM,272,RC,,,Outpatient,,,65,39,,11.7,18,,,percent of total billed charges,pays at 18% of total charges,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.5,50,,,percent of total billed charges,pays at 50% of total billed charges,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,32.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,65,
DERMABOND ADHESIVE,3640014,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
DRESSING AG STERILE,3640014,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
SEALER BIPOLAR TISSUE LIN,3640014,CDM,272,RC,,,Outpatient,,,825.5,495.3,,148.59,18,,,percent of total billed charges,pays at 18% of total charges,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.75,50,,,percent of total billed charges,pays at 50% of total billed charges,577.85,70,,,percent of total billed charges,70% of total billed charges,619.13,75,,,percent of total billed charges,75% of total billed charges,412.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,660.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,495.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,631.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,495.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,577.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,825.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,742.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.36,825.5,
PEN SMOKE VAC W/ACE BLADE,3640014,CDM,272,RC,,,Outpatient,,,208,124.8,,37.44,18,,,percent of total billed charges,pays at 18% of total charges,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104,50,,,percent of total billed charges,pays at 50% of total billed charges,145.6,70,,,percent of total billed charges,70% of total billed charges,156,75,,,percent of total billed charges,75% of total billed charges,104,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,208,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,208,
STAPLE SKIN PRECISE VISTA,3640014,CDM,272,RC,,,Outpatient,,,76,45.6,,13.68,18,,,percent of total billed charges,pays at 18% of total charges,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,50,,,percent of total billed charges,pays at 50% of total billed charges,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,76,
INJECTION EPIDURAL OF BLOOD OR CLOT PATC,3651509,CDM,761,RC,62273,HCPCS,Outpatient,,,1692,1015.2,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1692,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1269,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,1294.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,761.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1015.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,642.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,812.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1522.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1692,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,2073.62,
INJ ANESTH AGENT SNGL,3654415,CDM,761,RC,,,Outpatient,,,1397.5,838.5,,251.55,18,,,percent of total billed charges,pays at 18% of total charges,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1048.13,75,,,percent of total billed charges,75% of total billed charges,698.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1118,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,838.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1069.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,628.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,978.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,838.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,531.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,978.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1397.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1257.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,1397.5,
INJ ANESTH AGENT CONTINUOUS INFSN,3654416,CDM,761,RC,,,Outpatient,,,2057,1234.2,,370.26,18,,,percent of total billed charges,pays at 18% of total charges,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1028.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1542.75,75,,,percent of total billed charges,75% of total billed charges,1028.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1234.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1573.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,925.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1439.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1234.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,781.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1439.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2057,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1851.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,322.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.33,2057,
NERVE CRYOANALGESIA,3654640,CDM,761,RC,64640,HCPCS,Outpatient,,,1800,1080,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1800,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1350,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,1377,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,684,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1800,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,684,2742.49,
US GUIDED NEEDLE PLACMNT,3656942,CDM,402,RC,76942,HCPCS,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,446,
RECOVERY PACU 1 MIN,3659600,CDM,710,RC,,,Outpatient,,,21.3,12.78,,3.83,18,,,percent of total billed charges,pays at 18% of total charges,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.65,50,,,percent of total billed charges,pays at 50% of total billed charges,14.91,70,,,percent of total billed charges,70% of total billed charges,15.98,75,,,percent of total billed charges,75% of total billed charges,10.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.34,21.3,
PACU HOLD PRDCTVTY PER MIN,3659605,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BLADE BEAVER MINI,3660003,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
CYSTOTOME KRATZ,3660005,CDM,272,RC,,,Outpatient,,,78,46.8,,14.04,18,,,percent of total billed charges,pays at 18% of total charges,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39,50,,,percent of total billed charges,pays at 50% of total billed charges,54.6,70,,,percent of total billed charges,70% of total billed charges,58.5,75,,,percent of total billed charges,75% of total billed charges,39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.22,78,
MONOKA PVC SELF THREAD,3660011,CDM,272,RC,,,Outpatient,,,117,70.2,,21.06,18,,,percent of total billed charges,pays at 18% of total charges,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,50,,,percent of total billed charges,pays at 50% of total billed charges,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,58.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,117,
KNIFE CRESCENT,3660012,CDM,272,RC,,,Outpatient,,,105,63,,18.9,18,,,percent of total billed charges,pays at 18% of total charges,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,50,,,percent of total billed charges,pays at 50% of total billed charges,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,105,
PUNCTUM DILATOR PLUG,3660013,CDM,272,RC,,,Outpatient,,,22.5,13.5,,4.05,18,,,percent of total billed charges,pays at 18% of total charges,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,50,,,percent of total billed charges,pays at 50% of total billed charges,15.75,70,,,percent of total billed charges,70% of total billed charges,16.88,75,,,percent of total billed charges,75% of total billed charges,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,22.5,
KNIFE SLIT 3.0MM ANGLED,3660014,CDM,272,RC,,,Outpatient,,,96.5,57.9,,17.37,18,,,percent of total billed charges,pays at 18% of total charges,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.25,50,,,percent of total billed charges,pays at 50% of total billed charges,67.55,70,,,percent of total billed charges,70% of total billed charges,72.38,75,,,percent of total billed charges,75% of total billed charges,48.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,96.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,86.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,96.5,
PATCH CORNEAL GLYCERIN,3660015,CDM,278,RC,,,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.5,50,,,percent of total billed charges,pays at 50% of total billed charges,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,455,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
IMPLANT ENDOTINE TRANBLEP,3660016,CDM,278,RC,C1713,HCPCS,Outpatient,,,300,180,,54,18,,,percent of total billed charges,pays at 18% of total charges,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.01,300,
RETRACTOR IRIS,3660021,CDM,272,RC,,,Outpatient,,,135,81,,24.3,18,,,percent of total billed charges,pays at 18% of total charges,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,50,,,percent of total billed charges,pays at 50% of total billed charges,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,67.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,135,
SHIELD COLLAGEN CORNEAL,3660022,CDM,272,RC,,,Outpatient,,,66.15,39.69,,11.91,18,,,percent of total billed charges,pays at 18% of total charges,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.08,50,,,percent of total billed charges,pays at 50% of total billed charges,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,33.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,66.15,
CANNULA VISCOT THREADED,3660023,CDM,272,RC,,,Outpatient,,,17.25,10.35,,3.11,18,,,percent of total billed charges,pays at 18% of total charges,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.63,50,,,percent of total billed charges,pays at 50% of total billed charges,12.08,70,,,percent of total billed charges,70% of total billed charges,12.94,75,,,percent of total billed charges,75% of total billed charges,8.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,17.25,
TIP SILICONE I/A,3660024,CDM,272,RC,,,Outpatient,,,184.8,110.88,,33.26,18,,,percent of total billed charges,pays at 18% of total charges,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.4,50,,,percent of total billed charges,pays at 50% of total billed charges,129.36,70,,,percent of total billed charges,70% of total billed charges,138.6,75,,,percent of total billed charges,75% of total billed charges,92.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,184.8,
PACK ANTERIOR VITRECTOMY,3660025,CDM,272,RC,,,Outpatient,,,250,150,,45,18,,,percent of total billed charges,pays at 18% of total charges,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125,50,,,percent of total billed charges,pays at 50% of total billed charges,175,70,,,percent of total billed charges,70% of total billed charges,187.5,75,,,percent of total billed charges,75% of total billed charges,125,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.18,250,
TIP TAPERED POINT ABS,3660026,CDM,272,RC,,,Outpatient,,,106,63.6,,19.08,18,,,percent of total billed charges,pays at 18% of total charges,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53,50,,,percent of total billed charges,pays at 50% of total billed charges,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,106,
BLADE TUNNEL STRT,3660027,CDM,272,RC,,,Outpatient,,,20,12,,3.6,18,,,percent of total billed charges,pays at 18% of total charges,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,20,
SLEEVE INFUSION,3660028,CDM,272,RC,,,Outpatient,,,59.5,35.7,,10.71,18,,,percent of total billed charges,pays at 18% of total charges,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.75,50,,,percent of total billed charges,pays at 50% of total billed charges,41.65,70,,,percent of total billed charges,70% of total billed charges,44.63,75,,,percent of total billed charges,75% of total billed charges,29.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,59.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.32,59.5,
CYSTOME IRRIGATION,3660029,CDM,272,RC,,,Outpatient,,,14.6,8.76,,2.63,18,,,percent of total billed charges,pays at 18% of total charges,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.3,50,,,percent of total billed charges,pays at 50% of total billed charges,10.22,70,,,percent of total billed charges,70% of total billed charges,10.95,75,,,percent of total billed charges,75% of total billed charges,7.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,14.6,
TIP FLARED,3660030,CDM,272,RC,,,Outpatient,,,201.6,120.96,,36.29,18,,,percent of total billed charges,pays at 18% of total charges,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.8,50,,,percent of total billed charges,pays at 50% of total billed charges,141.12,70,,,percent of total billed charges,70% of total billed charges,151.2,75,,,percent of total billed charges,75% of total billed charges,100.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.59,201.6,
KNIFE SIDE PORT ANGLED,3660031,CDM,272,RC,,,Outpatient,,,28,16.8,,5.04,18,,,percent of total billed charges,pays at 18% of total charges,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14,50,,,percent of total billed charges,pays at 50% of total billed charges,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,28,
KNIFE FULL HANDLE STD,3660032,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
TIP ROUND 30 TURBOSONIC,3660033,CDM,272,RC,,,Outpatient,,,87.5,52.5,,15.75,18,,,percent of total billed charges,pays at 18% of total charges,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.75,50,,,percent of total billed charges,pays at 50% of total billed charges,61.25,70,,,percent of total billed charges,70% of total billed charges,65.63,75,,,percent of total billed charges,75% of total billed charges,43.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,87.5,
KNIFE 15 DEGREES,3660034,CDM,272,RC,,,Outpatient,,,38.25,22.95,,6.89,18,,,percent of total billed charges,pays at 18% of total charges,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,50,,,percent of total billed charges,pays at 50% of total billed charges,26.78,70,,,percent of total billed charges,70% of total billed charges,28.69,75,,,percent of total billed charges,75% of total billed charges,19.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,38.25,
IMPLANT MERIDIONAL RETINAL,3660039,CDM,278,RC,C1784,HCPCS,Outpatient,,,41.6,24.96,,7.49,18,,,percent of total billed charges,pays at 18% of total charges,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.12,70,,,percent of total billed charges,70% of total billed charges,31.2,75,,,percent of total billed charges,75% of total billed charges,20.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,33.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.52,41.6,
CANNULA DISP,3660042,CDM,272,RC,,,Outpatient,,,37.8,22.68,,6.8,18,,,percent of total billed charges,pays at 18% of total charges,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,50,,,percent of total billed charges,pays at 50% of total billed charges,26.46,70,,,percent of total billed charges,70% of total billed charges,28.35,75,,,percent of total billed charges,75% of total billed charges,18.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.92,37.8,
CANNULA DISP,3660043,CDM,272,RC,,,Outpatient,,,76.3,45.78,,13.73,18,,,percent of total billed charges,pays at 18% of total charges,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.15,50,,,percent of total billed charges,pays at 50% of total billed charges,53.41,70,,,percent of total billed charges,70% of total billed charges,57.23,75,,,percent of total billed charges,75% of total billed charges,38.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,76.3,
FORCEP DISP,3660044,CDM,272,RC,,,Outpatient,,,259,155.4,,46.62,18,,,percent of total billed charges,pays at 18% of total charges,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.5,50,,,percent of total billed charges,pays at 50% of total billed charges,181.3,70,,,percent of total billed charges,70% of total billed charges,194.25,75,,,percent of total billed charges,75% of total billed charges,129.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,207.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,155.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,181.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,181.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,259,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,233.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,259,
PROBE LASER,3660045,CDM,272,RC,,,Outpatient,,,368,220.8,,66.24,18,,,percent of total billed charges,pays at 18% of total charges,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184,50,,,percent of total billed charges,pays at 50% of total billed charges,257.6,70,,,percent of total billed charges,70% of total billed charges,276,75,,,percent of total billed charges,75% of total billed charges,184,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,294.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,281.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,257.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,368,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,331.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.67,368,
BACKFLUSH W/SOFT TIP,3660046,CDM,272,RC,,,Outpatient,,,99,59.4,,17.82,18,,,percent of total billed charges,pays at 18% of total charges,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.5,50,,,percent of total billed charges,pays at 50% of total billed charges,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,49.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,99,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.51,99,
SCRAPPER FLEXLOOP,3660047,CDM,272,RC,,,Outpatient,,,184.5,110.7,,33.21,18,,,percent of total billed charges,pays at 18% of total charges,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.25,50,,,percent of total billed charges,pays at 50% of total billed charges,129.15,70,,,percent of total billed charges,70% of total billed charges,138.38,75,,,percent of total billed charges,75% of total billed charges,92.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,129.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.91,184.5,
BLADE MVR,3660048,CDM,272,RC,,,Outpatient,,,46.2,27.72,,8.32,18,,,percent of total billed charges,pays at 18% of total charges,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.1,50,,,percent of total billed charges,pays at 50% of total billed charges,32.34,70,,,percent of total billed charges,70% of total billed charges,34.65,75,,,percent of total billed charges,75% of total billed charges,23.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.24,46.2,
PIK LIGHTED DISP,3660049,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
CHANDELIER DISP,3660050,CDM,272,RC,,,Outpatient,,,161.25,96.75,,29.03,18,,,percent of total billed charges,pays at 18% of total charges,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.63,50,,,percent of total billed charges,pays at 50% of total billed charges,112.88,70,,,percent of total billed charges,70% of total billed charges,120.94,75,,,percent of total billed charges,75% of total billed charges,80.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.27,161.25,
PROBE ENDOIATHERMY,3660051,CDM,272,RC,,,Outpatient,,,73.5,44.1,,13.23,18,,,percent of total billed charges,pays at 18% of total charges,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.75,50,,,percent of total billed charges,pays at 50% of total billed charges,51.45,70,,,percent of total billed charges,70% of total billed charges,55.13,75,,,percent of total billed charges,75% of total billed charges,36.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,66.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,73.5,
LENS ASPHERIC MACULAR,3660052,CDM,272,RC,,,Outpatient,,,61.25,36.75,,11.03,18,,,percent of total billed charges,pays at 18% of total charges,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.63,50,,,percent of total billed charges,pays at 50% of total billed charges,42.88,70,,,percent of total billed charges,70% of total billed charges,45.94,75,,,percent of total billed charges,75% of total billed charges,30.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,61.25,
KIT AUTO GAS FILL,3660053,CDM,272,RC,,,Outpatient,,,102.38,61.43,,18.43,18,,,percent of total billed charges,pays at 18% of total charges,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.19,50,,,percent of total billed charges,pays at 50% of total billed charges,71.67,70,,,percent of total billed charges,70% of total billed charges,76.79,75,,,percent of total billed charges,75% of total billed charges,51.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102.38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,92.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,102.38,
KIT VISCOUS FLUID OIL,3660054,CDM,272,RC,,,Outpatient,,,89,53.4,,16.02,18,,,percent of total billed charges,pays at 18% of total charges,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.5,50,,,percent of total billed charges,pays at 50% of total billed charges,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,44.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,89,
KIT FRAGMENTATION HP,3660055,CDM,272,RC,,,Outpatient,,,81.51,48.91,,14.67,18,,,percent of total billed charges,pays at 18% of total charges,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.76,50,,,percent of total billed charges,pays at 50% of total billed charges,57.06,70,,,percent of total billed charges,70% of total billed charges,61.13,75,,,percent of total billed charges,75% of total billed charges,40.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.51,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.77,81.51,
KIT PERFLUORON,3660056,CDM,272,RC,,,Outpatient,,,333.95,200.37,,60.11,18,,,percent of total billed charges,pays at 18% of total charges,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.98,50,,,percent of total billed charges,pays at 50% of total billed charges,233.77,70,,,percent of total billed charges,70% of total billed charges,250.46,75,,,percent of total billed charges,75% of total billed charges,166.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,267.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,200.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,255.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333.95,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,300.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.33,333.95,
SOLN SILIKON OIL,3660057,CDM,272,RC,C1814,HCPCS,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
SET SMOKE EVAC INSUFFLATION,3660058,CDM,272,RC,,,Outpatient,,,173.25,103.95,,31.19,18,,,percent of total billed charges,pays at 18% of total charges,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.63,50,,,percent of total billed charges,pays at 50% of total billed charges,121.28,70,,,percent of total billed charges,70% of total billed charges,129.94,75,,,percent of total billed charges,75% of total billed charges,86.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,173.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,155.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,173.25,
SLEEVE SILICONE,3660059,CDM,278,RC,,,Outpatient,,,20.5,12.3,,3.69,18,,,percent of total billed charges,pays at 18% of total charges,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.25,50,,,percent of total billed charges,pays at 50% of total billed charges,14.35,70,,,percent of total billed charges,70% of total billed charges,15.38,75,,,percent of total billed charges,75% of total billed charges,10.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,20.5,
SET OPTIC HD LENS DISP,3660060,CDM,272,RC,,,Outpatient,,,1125.02,675.01,,202.5,18,,,percent of total billed charges,pays at 18% of total charges,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,562.51,50,,,percent of total billed charges,pays at 50% of total billed charges,787.51,70,,,percent of total billed charges,70% of total billed charges,843.77,75,,,percent of total billed charges,75% of total billed charges,562.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,900.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,860.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,787.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,675.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,427.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,787.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1125.02,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1012.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.29,1125.02,
LENS CONTACT HTC SUPERVIEW DISP,3660061,CDM,272,RC,V2599,HCPCS,Outpatient,,,653.25,391.95,,,,,,Other,Not Separately reimbursable,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.63,50,,,percent of total billed charges,pays at 50% of total billed charges,457.28,70,,,percent of total billed charges,70% of total billed charges,489.94,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,522.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,457.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,391.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,457.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,587.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.36,587.93,
DROPS OPTHALMIC LUBRICANT,3660062,CDM,272,RC,,,Outpatient,,,285.15,171.09,,,,,,Other,Not Separately reimbursable,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.58,50,,,percent of total billed charges,pays at 50% of total billed charges,199.61,70,,,percent of total billed charges,70% of total billed charges,213.86,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,228.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,199.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,199.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,256.64,
STENT MINI MONOKA,3660080,CDM,278,RC,C1783,HCPCS,Outpatient,,,126,75.6,,,,,,Other,Not Separately reimbursable,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,126,
BRUSH BIPOLAR W CORD 18G,3660081,CDM,272,RC,,,Outpatient,,,53,31.8,,,,,,Other,Not Separately reimbursable,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.5,50,,,percent of total billed charges,pays at 50% of total billed charges,37.1,70,,,percent of total billed charges,70% of total billed charges,39.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.31,47.7,
PUNCH CORNEAL,3660083,CDM,272,RC,,,Outpatient,,,108.5,65.1,,,,,,Other,Not Separately reimbursable,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.25,50,,,percent of total billed charges,pays at 50% of total billed charges,75.95,70,,,percent of total billed charges,70% of total billed charges,81.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17,97.65,
STRIP SILICONE,3660090,CDM,278,RC,,,Outpatient,,,26,15.6,,,,,,Other,Not Separately reimbursable,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13,50,,,percent of total billed charges,pays at 50% of total billed charges,18.2,70,,,percent of total billed charges,70% of total billed charges,19.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,18.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.07,26,
TIRE WIDE GROOVE,3660091,CDM,272,RC,,,Outpatient,,,38.4,23.04,,,,,,Other,Not Separately reimbursable,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.2,50,,,percent of total billed charges,pays at 50% of total billed charges,26.88,70,,,percent of total billed charges,70% of total billed charges,28.8,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,30.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.02,34.56,
SPONGE EYE,3660092,CDM,272,RC,,,Outpatient,,,81.3,48.78,,,,,,Other,Not Separately reimbursable,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.65,50,,,percent of total billed charges,pays at 50% of total billed charges,56.91,70,,,percent of total billed charges,70% of total billed charges,60.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,65.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.74,73.17,
PACK RETINA,3660093,CDM,272,RC,,,Outpatient,,,727.6,436.56,,,,,,Other,Not Separately reimbursable,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.8,50,,,percent of total billed charges,pays at 50% of total billed charges,509.32,70,,,percent of total billed charges,70% of total billed charges,545.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,582.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,509.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,436.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,509.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,654.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.01,654.84,
SHIELD EASY,3660100,CDM,272,RC,,,Outpatient,,,10.5,6.3,,,,,,Other,Not Separately reimbursable,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,50,,,percent of total billed charges,pays at 50% of total billed charges,7.35,70,,,percent of total billed charges,70% of total billed charges,7.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,9.45,
FORCEP BIOPOLAR,3660108,CDM,272,RC,,,Outpatient,,,51.5,30.9,,,,,,Other,Not Separately reimbursable,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,46.35,
PACK INFINITY .9MM INFUSE,3660125,CDM,272,RC,,,Outpatient,,,127.5,76.5,,,,,,Other,Not Separately reimbursable,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.75,50,,,percent of total billed charges,pays at 50% of total billed charges,89.25,70,,,percent of total billed charges,70% of total billed charges,95.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,114.75,
Destruction of 1-14 common or plantar warts,3660158,CDM,360,RC,17110,HCPCS,Outpatient,,,2551.2,1530.72,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1785.84,70,,,percent of total billed charges,70% of total billed charges,1913.4,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2040.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,1951.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1148.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1785.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1530.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1785.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1224.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,2296.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,2296.08,
CANNULA MICRO J SHAPED,3661190,CDM,272,RC,,,Outpatient,,,28.5,17.1,,,,,,Other,Not Separately reimbursable,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.25,50,,,percent of total billed charges,pays at 50% of total billed charges,19.95,70,,,percent of total billed charges,70% of total billed charges,21.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,22.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,25.65,
KNIFE CLEAR CUT,3661337,CDM,272,RC,,,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,50,,,percent of total billed charges,pays at 50% of total billed charges,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
CLIP VIEW STABILIZER DISP,3661850,CDM,272,RC,,,Outpatient,,,90,54,,,,,,Other,Not Separately reimbursable,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,50,,,percent of total billed charges,pays at 50% of total billed charges,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.1,81,
CONFORMER EYE LARGE,3661859,CDM,278,RC,,,Outpatient,,,75.5,45.3,,,,,,Other,Not Separately reimbursable,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.75,50,,,percent of total billed charges,pays at 50% of total billed charges,52.85,70,,,percent of total billed charges,70% of total billed charges,56.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,75.5,
EXPANDER PUPIL GRAETHER,3661860,CDM,272,RC,,,Outpatient,,,135,81,,,,,,Other,Not Separately reimbursable,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,50,,,percent of total billed charges,pays at 50% of total billed charges,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,121.5,
LENS MTA4UO,3661907,CDM,276,RC,C1780,HCPCS,Outpatient,,,189,113.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.3,70,,,percent of total billed charges,70% of total billed charges,141.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.82,170.1,
ALCON 45 DEGREE 1.1MM ABS TIP,3663902,CDM,272,RC,,,Outpatient,,,201.5,120.9,,,,,,Other,Not Separately reimbursable,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.75,50,,,percent of total billed charges,pays at 50% of total billed charges,141.05,70,,,percent of total billed charges,70% of total billed charges,151.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,161.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,181.35,
DCR SET,3663957,CDM,272,RC,,,Outpatient,,,106,63.6,,,,,,Other,Not Separately reimbursable,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53,50,,,percent of total billed charges,pays at 50% of total billed charges,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.61,95.4,
HYDRODISSECTOR NUCLEUS,3664022,CDM,272,RC,,,Outpatient,,,24,14.4,,,,,,Other,Not Separately reimbursable,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,21.6,
SHUNT EXPRESS OPTONAL,3664220,CDM,278,RC,C1783,HCPCS,Outpatient,,,1139.5,683.7,,,,,,Other,Not Separately reimbursable,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.65,70,,,percent of total billed charges,70% of total billed charges,854.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,911.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1139.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,196.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,797.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,683.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,433.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,797.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1139.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,178.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.56,1139.5,
IMPLANT EYE GLAUCOMA DRAINAGE,3664221,CDM,278,RC,C1783,HCPCS,Outpatient,,,864.5,518.7,,,,,,Other,Not Separately reimbursable,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.15,70,,,percent of total billed charges,70% of total billed charges,648.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,691.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,148.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,605.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,518.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,605.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,864.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.47,864.5,
STENT TRABECULAR MICRO BYPASS,3664222,CDM,278,RC,C1783,HCPCS,Outpatient,,,2373,1423.8,,,,,,Other,Not Separately reimbursable,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1661.1,70,,,percent of total billed charges,70% of total billed charges,1779.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1898.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2373,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,408.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1067.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1661.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1423.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,901.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1661.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1139.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2373,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,371.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.85,2373,
PACK EYE SURGERY PROC,3664389,CDM,272,RC,,,Outpatient,,,504.9,302.94,,,,,,Other,Not Separately reimbursable,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.45,50,,,percent of total billed charges,pays at 50% of total billed charges,353.43,70,,,percent of total billed charges,70% of total billed charges,378.68,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,403.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.12,454.41,
LENS CORRECTIVE IOL,3665465,CDM,276,RC,V2788,HCPCS,Outpatient,,,1551,930.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1085.7,70,,,percent of total billed charges,70% of total billed charges,1163.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1240.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1186.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1085.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,930.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1085.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1395.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.38,1395.9,
LENS 5N60WF,3665466,CDM,276,RC,C1780,HCPCS,Outpatient,,,308.55,185.13,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.99,70,,,percent of total billed charges,70% of total billed charges,231.41,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,246.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,215.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,277.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.25,277.7,
LENS SN60AT,3665511,CDM,276,RC,C1780,HCPCS,Outpatient,,,340,204,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.2,306,
Removal of cataract with insertion of lens,3666005,CDM,360,RC,66984,HCPCS,Outpatient,,,2008.4,1205.04,,6949.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1963.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1963.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3838.58,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1405.88,70,,,percent of total billed charges,70% of total billed charges,1506.3,75,,,percent of total billed charges,75% of total billed charges,3533.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1606.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6871.01,350,,,Fee Schedule,350% of CMS OPPS Rate,2002.4,103,,,Fee Schedule,103% of CMS OPPS Rate,1536.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,903.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1405.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1205.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1405.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4515.22,100,,,Fee Schedule,100% of CMS OPPS Rate,964.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.14,100,,,Fee Schedule,100% of CMS OPPS Rate,903.78,6949.53,
GRAFT AMNIOGRAFT 15X10CM,3666008,CDM,278,RC,V2790,HCPCS,Outpatient,,,889.35,533.61,,,,,,Other,Not Separately reimbursable,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.68,50,,,percent of total billed charges,pays at 50% of total billed charges,622.55,70,,,percent of total billed charges,70% of total billed charges,667.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,711.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,889.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,153.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,622.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,533.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,622.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,889.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.36,889.35,
LENS CLRFLXC,3666154,CDM,276,RC,C1780,HCPCS,Outpatient,,,222.5,133.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.75,70,,,percent of total billed charges,70% of total billed charges,166.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.55,200.25,
ASSEMBLY CLAVICLE PIN,3666493,CDM,278,RC,C1776,HCPCS,Outpatient,,,1612,967.2,,,,,,Other,Not Separately reimbursable,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.4,70,,,percent of total billed charges,70% of total billed charges,1209,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1289.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1612,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,277.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,725.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1128.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,967.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,612.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1128.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1612,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.6,1612,
EXCISION BENIGN LESN FACE,3668007,CDM,360,RC,11441,HCPCS,Outpatient,,,1844,1106.4,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1290.8,70,,,percent of total billed charges,70% of total billed charges,1383,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1475.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1410.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,829.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1290.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1106.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1290.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,885.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1659.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,2088.52,
NASOLCRML DUCT BALON DIL,3669474,CDM,360,RC,68816,HCPCS,Outpatient,,,3257.6,1954.56,,6804,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1922.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1922.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3693.16,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2280.32,70,,,percent of total billed charges,70% of total billed charges,2443.2,75,,,percent of total billed charges,75% of total billed charges,3459.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2606.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6727.12,350,,,Fee Schedule,350% of CMS OPPS Rate,1960.47,103,,,Fee Schedule,103% of CMS OPPS Rate,2492.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1465.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2280.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1954.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2280.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,4420.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2931.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1465.92,6804,
LENS MN60AC,3669715,CDM,276,RC,C1780,HCPCS,Outpatient,,,234.5,140.7,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.15,70,,,percent of total billed charges,70% of total billed charges,175.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,187.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,164.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.11,211.05,
LENS SN60T3,3669716,CDM,276,RC,V2787,HCPCS,Outpatient,,,707.85,424.71,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.93,50,,,percent of total billed charges,pays at 50% of total billed charges,495.5,70,,,percent of total billed charges,70% of total billed charges,530.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,566.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,495.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,424.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,495.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,637.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.98,637.07,
CROUCH CORNEAL PROTECTOR,3669812,CDM,272,RC,,,Outpatient,,,49.5,29.7,,,,,,Other,Not Separately reimbursable,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,44.55,
LENS ACRYLIC IOL,3669908,CDM,276,RC,V2787,HCPCS,Outpatient,,,442.5,265.5,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.25,50,,,percent of total billed charges,pays at 50% of total billed charges,309.75,70,,,percent of total billed charges,70% of total billed charges,331.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,354,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,309.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,309.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,398.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.15,398.25,
LENS ACRYLIC IOL,3669909,CDM,276,RC,V2787,HCPCS,Outpatient,,,190,114,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95,50,,,percent of total billed charges,pays at 50% of total billed charges,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.2,171,
LENS ACRYLIC PRELOADED,3669910,CDM,276,RC,V2787,HCPCS,Outpatient,,,246,147.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123,50,,,percent of total billed charges,pays at 50% of total billed charges,172.2,70,,,percent of total billed charges,70% of total billed charges,184.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,172.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.48,221.4,
ANCHOR ANKLE FIXATION,3669911,CDM,278,RC,C1713,HCPCS,Outpatient,,,1096,657.6,,,,,,Other,Not Separately reimbursable,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.2,70,,,percent of total billed charges,70% of total billed charges,822,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,876.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,188.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,767.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,657.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,767.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1096,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.74,1096,
PRE ADMISSIONS PRODUCTIVITY,3670001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PRODUCTIVITY ONLY EARLY LABOR EVAL,3700001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Vaginal delivery,3700003,CDM,720,RC,59409,HCPCS,Outpatient,,,6762,4057.2,,9099.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2570.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4633.95,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4733.4,70,,,percent of total billed charges,70% of total billed charges,5071.5,75,,,percent of total billed charges,75% of total billed charges,4626.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8996.49,350,,,Fee Schedule,350% of CMS OPPS Rate,2621.82,103,,,Fee Schedule,103% of CMS OPPS Rate,5172.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3042.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4733.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4057.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,161,100,,,Case rate,Pays based on per visit ,4733.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5911.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3245.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,6085.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,161,9099.29,
OBSERVATION-PER HR,3700005,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
FETAL MONITOR,3700008,CDM,720,RC,59050,HCPCS,Outpatient,,,229.68,137.81,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.84,50,,,percent of total billed charges,pays at 50% of total billed charges,160.78,70,,,percent of total billed charges,70% of total billed charges,172.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,183.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161,100,,,Case rate,Pays based on per visit ,160.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.36,206.71,
Outpatient visit of established patient not requiring a physician,3700010,CDM,720,RC,99211,HCPCS,Outpatient,,,123,73.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161,100,,,Case rate,Pays based on per visit ,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,161,
PRODUCTIVITY ONLY EARLY LABOR EVAL,3700010X,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Outpatient visit of established patient not requiring a physician,3700010X,CDM,720,RC,99211,HCPCS,Outpatient,,,123,73.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161,100,,,Case rate,Pays based on per visit ,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.77,161,
SCALP ELECTRODE,3700013,CDM,272,RC,,,Outpatient,,,25,15,,,,,,Other,Not Separately reimbursable,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,22.5,
REC PP FBC L&D OBSERVATION HR,3700020,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,,,,,Other,Not Separately reimbursable,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
FBC L&D OBSERVATION HR,3700023,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,,,,,Other,Not Separately reimbursable,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
BALLOON CERVICAL RIPENING,3700168,CDM,272,RC,,,Outpatient,,,533,319.8,,,,,,Other,Not Separately reimbursable,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.5,50,,,percent of total billed charges,pays at 50% of total billed charges,373.1,70,,,percent of total billed charges,70% of total billed charges,399.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,426.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,373.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,319.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,202.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,373.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,479.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.52,479.7,
BIOPSY SINGLE LESION,3701100,CDM,761,RC,11100,HCPCS,Outpatient,,,208.01,124.81,,,,,,Other,Not Separately reimbursable,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,156.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,166.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,145.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.6,633.69,
BIOPSY EA  ADDTL LESION,3701101,CDM,761,RC,11101,HCPCS,Outpatient,,,122.77,73.66,,,,,,Other,Not Separately reimbursable,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,98.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,85.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.24,110.49,
INJECTION EPIDURAL OF BLOOD OR CLOT PATC,3703500,CDM,720,RC,62273,HCPCS,Outpatient,,,1692,1015.2,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1184.4,70,,,percent of total billed charges,70% of total billed charges,1269,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,1294.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,761.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1015.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,161,100,,,Case rate,Pays based on per visit ,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,812.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1522.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,161,2073.62,
RPR SUPERFICIALWND 0-2.5,3703503,CDM,720,RC,,,Outpatient,,,356.84,214.1,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,249.79,70,,,percent of total billed charges,70% of total billed charges,267.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161,100,,,Case rate,Pays based on per visit ,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,321.16,
A common prenatal test used to check on a baby's health.,3706151,CDM,920,RC,59025,HCPCS,Outpatient,,,449,269.4,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,314.3,70,,,percent of total billed charges,70% of total billed charges,336.75,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,343.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,202.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,314.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,340,100,,,Case rate,Pays based on per visit ,314.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,215.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,404.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,70.36,573.26,
STRESS TEST OB,3706153,CDM,920,RC,59020,HCPCS,Outpatient,,,548,328.8,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,383.6,70,,,percent of total billed charges,70% of total billed charges,411,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,438.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,419.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,246.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,383.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,328.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,340,100,,,Case rate,Pays based on per visit ,383.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,263.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,493.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,85.87,573.26,
MECONIUM-ASPIRATOR,3706162,CDM,272,RC,,,Outpatient,,,12.5,7.5,,,,,,Other,Not Separately reimbursable,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,11.25,
IUPC,3706166,CDM,272,RC,,,Outpatient,,,192,115.2,,,,,,Other,Not Separately reimbursable,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,50,,,percent of total billed charges,pays at 50% of total billed charges,134.4,70,,,percent of total billed charges,70% of total billed charges,144,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,153.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,134.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,172.8,
INJECTION SQ OR IM,3706167,CDM,720,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,161,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3706168,CDM,720,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,161,100,,,Case rate,Pays based on per visit ,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,161,664.77,
HYDRATION INFUSION INITIAL HR,3706169,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3706170,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3706171,CDM,720,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,161,100,,,Case rate,Pays based on per visit ,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,161,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3706172,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3706173,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3706174,CDM,720,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161,100,,,Case rate,Pays based on per visit ,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,161,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3706175,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,3706176,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,,,,,Other,Not Separately reimbursable,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
TRAY STAPLE/SUTURE REMOVAL,3708201,CDM,272,RC,,,Outpatient,,,3.15,1.89,,,,,,Other,Not Separately reimbursable,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.58,50,,,percent of total billed charges,pays at 50% of total billed charges,2.21,70,,,percent of total billed charges,70% of total billed charges,2.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,2.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,2.84,
CIRCUMCISION NEONATE,3708301,CDM,723,RC,54150,HCPCS,Outpatient,,,4795,2877,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3388.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3356.5,70,,,percent of total billed charges,70% of total billed charges,3596.25,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3836,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,3668.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2157.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3356.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2877,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3356.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2301.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4315.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,5969.39,
Urine pregnancy test,3731025,CDM,300,RC,81025,HCPCS,Outpatient,,,21.75,13.05,,30.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,15.23,70,,,percent of total billed charges,70% of total billed charges,16.31,75,,,percent of total billed charges,75% of total billed charges,15.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.13,350,,,Fee Schedule,350% of CMS OPPS Rate,8.78,102,,,Fee Schedule,102% of CMS OPPS Rate,16.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,100% of UHC Fee Schedule,15.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,230,,,Fee Schedule,230% of CMS OPPS Rate,10.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,30.47,
SANE FOLLOW UP VISIT PRODUCTIVITY,3738026,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
FORENSIC MED EXAM VICTIM PRODUCTIVITY,3738028,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
FORENSIC MED EXAM SUSPECT,3738029,CDM,450,RC,,,Outpatient,,,66,39.6,,,,,,Other,Not Separately reimbursable,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,49.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,59.4,
DNA ONLY VICTIM,3738030,CDM,450,RC,,,Outpatient,,,66,39.6,,,,,,Other,Not Separately reimbursable,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,49.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,59.4,
DNA ONLY SUSPECT,3738032,CDM,450,RC,,,Outpatient,,,66,39.6,,,,,,Other,Not Separately reimbursable,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,49.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,59.4,
TOXICOLOGY ONLY VICTIM,3738034,CDM,450,RC,,,Outpatient,,,66,39.6,,,,,,Other,Not Separately reimbursable,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,49.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,59.4,
TOXICOLOGY ONLY SUSPECT,3738036,CDM,450,RC,,,Outpatient,,,66,39.6,,,,,,Other,Not Separately reimbursable,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,49.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.34,59.4,
DRESSING-TRANSPARENT,3750132,CDM,272,RC,,,Outpatient,,,6.5,3.9,,,,,,Other,Not Separately reimbursable,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,5.85,
DRESSING-TRANSPARENT 4X10,3750136,CDM,272,RC,,,Outpatient,,,18,10.8,,,,,,Other,Not Separately reimbursable,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,16.2,
SYS FOUR LAYER BANDAGE,3750145,CDM,272,RC,,,Outpatient,,,29.5,17.7,,,,,,Other,Not Separately reimbursable,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,26.55,
BANDAGE COMPRESSION,3750150,CDM,272,RC,,,Outpatient,,,16,9.6,,,,,,Other,Not Separately reimbursable,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,50,,,percent of total billed charges,pays at 50% of total billed charges,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,14.4,
PUMP BREAST ONE-HAND W/FLEXISHIELD,3750160,CDM,272,RC,,,Outpatient,,,39,23.4,,,,,,Other,Not Separately reimbursable,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,35.1,
SYS COLLECTION DUAL HYGIENIKIT,3750161,CDM,272,RC,,,Outpatient,,,48,28.8,,,,,,Other,Not Separately reimbursable,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,50,,,percent of total billed charges,pays at 50% of total billed charges,33.6,70,,,percent of total billed charges,70% of total billed charges,36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.52,43.2,
PACK PERI/GYN II,3750162,CDM,272,RC,,,Outpatient,,,12,7.2,,,,,,Other,Not Separately reimbursable,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,50,,,percent of total billed charges,pays at 50% of total billed charges,8.4,70,,,percent of total billed charges,70% of total billed charges,9,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,10.8,
KIT BREAST SYMPHONY,3750163,CDM,272,RC,,,Outpatient,,,45,27,,,,,,Other,Not Separately reimbursable,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,50,,,percent of total billed charges,pays at 50% of total billed charges,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,40.5,
INFUSOR,3750164,CDM,272,RC,,,Outpatient,,,49.5,29.7,,,,,,Other,Not Separately reimbursable,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,44.55,
BABY EVACUATORS MYSTIC II BELL CUP,3750165,CDM,272,RC,,,Outpatient,,,59,35.4,,,,,,Other,Not Separately reimbursable,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.5,50,,,percent of total billed charges,pays at 50% of total billed charges,41.3,70,,,percent of total billed charges,70% of total billed charges,44.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,53.1,
BALLOON POST PARTUM BAKRI,3750166,CDM,272,RC,,,Outpatient,,,325.5,195.3,,,,,,Other,Not Separately reimbursable,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.75,50,,,percent of total billed charges,pays at 50% of total billed charges,227.85,70,,,percent of total billed charges,70% of total billed charges,244.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,260.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,227.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.01,292.95,
SALINE INSTLTN COMPONENT POST PARTUM BLN,3750167,CDM,272,RC,,,Outpatient,,,21,12.6,,,,,,Other,Not Separately reimbursable,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,18.9,
RESUSCITATOR NEO W MANOMETER,3750169,CDM,272,RC,,,Outpatient,,,73.5,44.1,,,,,,Other,Not Separately reimbursable,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,50,,,percent of total billed charges,pays at 50% of total billed charges,51.45,70,,,percent of total billed charges,70% of total billed charges,55.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,58.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,66.15,
SURGICEL,3750170,CDM,272,RC,,,Outpatient,,,33.5,20.1,,,,,,Other,Not Separately reimbursable,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.75,50,,,percent of total billed charges,pays at 50% of total billed charges,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,30.15,
SURGICEL 2X3,3750174,CDM,272,RC,,,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.5,50,,,percent of total billed charges,pays at 50% of total billed charges,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
DRESSING TELFA,3750204,CDM,272,RC,,,Outpatient,,,1,0.6,,,,,,Other,Not Separately reimbursable,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,0.9,
KIT INTRODUCER TRACH,3750205,CDM,272,RC,,,Outpatient,,,430,258,,,,,,Other,Not Separately reimbursable,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215,50,,,percent of total billed charges,pays at 50% of total billed charges,301,70,,,percent of total billed charges,70% of total billed charges,322.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.38,387,
GAUZE STRL 4X4,3750244,CDM,272,RC,,,Outpatient,,,6.5,3.9,,,,,,Other,Not Separately reimbursable,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,5.85,
SKIN PREP PAD,3750245,CDM,272,RC,,,Outpatient,,,1.75,1.05,,,,,,Other,Not Separately reimbursable,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.88,50,,,percent of total billed charges,pays at 50% of total billed charges,1.23,70,,,percent of total billed charges,70% of total billed charges,1.31,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.27,1.58,
DRAWTEX,3750246,CDM,272,RC,,,Outpatient,,,16.33,9.8,,,,,,Other,Not Separately reimbursable,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.17,50,,,percent of total billed charges,pays at 50% of total billed charges,11.43,70,,,percent of total billed charges,70% of total billed charges,12.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,13.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.56,14.7,
HYDRATING GEL,3750247,CDM,272,RC,,,Outpatient,,,5.48,3.29,,,,,,Other,Not Separately reimbursable,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.74,50,,,percent of total billed charges,pays at 50% of total billed charges,3.84,70,,,percent of total billed charges,70% of total billed charges,4.11,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,4.93,
ACTICOAT 4X4,3750248,CDM,272,RC,,,Outpatient,,,19.15,11.49,,,,,,Other,Not Separately reimbursable,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.58,50,,,percent of total billed charges,pays at 50% of total billed charges,13.41,70,,,percent of total billed charges,70% of total billed charges,14.36,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,15.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3,17.24,
WRAP-COBAN 2 IN,3750352,CDM,272,RC,,,Outpatient,,,16,9.6,,,,,,Other,Not Separately reimbursable,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,50,,,percent of total billed charges,pays at 50% of total billed charges,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,14.4,
WRAP-COBAN 3IN,3750353,CDM,272,RC,,,Outpatient,,,16,9.6,,,,,,Other,Not Separately reimbursable,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,50,,,percent of total billed charges,pays at 50% of total billed charges,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.51,14.4,
WRAP COBAN 4 OR 6 INCH,3750354,CDM,272,RC,,,Outpatient,,,26.5,15.9,,,,,,Other,Not Separately reimbursable,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,50,,,percent of total billed charges,pays at 50% of total billed charges,18.55,70,,,percent of total billed charges,70% of total billed charges,19.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.15,23.85,
PAD ABDOMINAL,3750355,CDM,272,RC,,,Outpatient,,,1,0.6,,,,,,Other,Not Separately reimbursable,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,0.9,
CATH EXT FEMALE PUREWICK,3750356,CDM,272,RC,,,Outpatient,,,16.25,9.75,,,,,,Other,Not Separately reimbursable,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.13,50,,,percent of total billed charges,pays at 50% of total billed charges,11.38,70,,,percent of total billed charges,70% of total billed charges,12.19,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.55,14.63,
PACK DELIVERY ROOM,3750962,CDM,272,RC,,,Outpatient,,,126,75.6,,,,,,Other,Not Separately reimbursable,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,50,,,percent of total billed charges,pays at 50% of total billed charges,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,113.4,
BOTTLE THORADRAIN III REP,3751333,CDM,272,RC,,,Outpatient,,,81,48.6,,,,,,Other,Not Separately reimbursable,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,72.9,
BANDAGE KERLIX ROLL,3751430,CDM,272,RC,,,Outpatient,,,6.5,3.9,,,,,,Other,Not Separately reimbursable,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,5.85,
VALVE PNEUMOSTAT HEIMLICH,3751655,CDM,272,RC,,,Outpatient,,,63,37.8,,,,,,Other,Not Separately reimbursable,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,50,,,percent of total billed charges,pays at 50% of total billed charges,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,56.7,
CHEST TUBE INSERTION SUPP,3751660,CDM,272,RC,,,Outpatient,,,300.5,180.3,,,,,,Other,Not Separately reimbursable,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.25,50,,,percent of total billed charges,pays at 50% of total billed charges,210.35,70,,,percent of total billed charges,70% of total billed charges,225.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,240.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,270.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.09,270.45,
DRAIN CHEST DRY SGL,3751664,CDM,272,RC,,,Outpatient,,,236,141.6,,,,,,Other,Not Separately reimbursable,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118,50,,,percent of total billed charges,pays at 50% of total billed charges,165.2,70,,,percent of total billed charges,70% of total billed charges,177,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,165.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.98,212.4,
GROUNDING PAD-ADULT V/L,3751860,CDM,272,RC,,,Outpatient,,,49.5,29.7,,,,,,Other,Not Separately reimbursable,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,44.55,
"KERLIX ROLL-4.5X147""",3751940,CDM,270,RC,,,Outpatient,,,6.5,3.9,,,,,,Other,Not Separately reimbursable,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,5.85,
KIT MULTI LUMEN CVC,3751941,CDM,270,RC,,,Outpatient,,,107,64.2,,,,,,Other,Not Separately reimbursable,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.5,50,,,percent of total billed charges,pays at 50% of total billed charges,74.9,70,,,percent of total billed charges,70% of total billed charges,80.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.77,96.3,
KIT BIOPATCH DRESSING,3751958,CDM,272,RC,A6257,HCPCS,Outpatient,,,46,27.6,,,,,,Other,Not Separately reimbursable,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,41.4,
KIT-IRRIG PISTON SYRINGE,3751970,CDM,272,RC,,,Outpatient,,,24,14.4,,,,,,Other,Not Separately reimbursable,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,21.6,
KIT-PERCUTNS INTRO ARROW,3752005,CDM,272,RC,,,Outpatient,,,222.5,133.5,,,,,,Other,Not Separately reimbursable,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.25,50,,,percent of total billed charges,pays at 50% of total billed charges,155.75,70,,,percent of total billed charges,70% of total billed charges,166.88,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,178,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.87,200.25,
BLANKET DUOTHERM/WARM TOU,3752180,CDM,272,RC,,,Outpatient,,,229,137.4,,,,,,Other,Not Separately reimbursable,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,50,,,percent of total billed charges,pays at 50% of total billed charges,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,206.1,
PENCILETTE-SURG-SWTCH V/L,3752290,CDM,272,RC,,,Outpatient,,,71.5,42.9,,,,,,Other,Not Separately reimbursable,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.75,50,,,percent of total billed charges,pays at 50% of total billed charges,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.2,64.35,
BAG FEEDING TUBE,3752528,CDM,272,RC,,,Outpatient,,,12,7.2,,,,,,Other,Not Separately reimbursable,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,50,,,percent of total billed charges,pays at 50% of total billed charges,8.4,70,,,percent of total billed charges,70% of total billed charges,9,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,10.8,
TUBE FEEDING W STYLET,3752533,CDM,272,RC,,,Outpatient,,,35.5,21.3,,,,,,Other,Not Separately reimbursable,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,50,,,percent of total billed charges,pays at 50% of total billed charges,24.85,70,,,percent of total billed charges,70% of total billed charges,26.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.56,31.95,
SET-EXCHANGE TRANSFUSION,3752535,CDM,272,RC,,,Outpatient,,,237.5,142.5,,,,,,Other,Not Separately reimbursable,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.75,50,,,percent of total billed charges,pays at 50% of total billed charges,166.25,70,,,percent of total billed charges,70% of total billed charges,178.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,213.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,213.75,
THORACENTESIS,3752554,CDM,761,RC,,,Outpatient,,,1077.48,646.49,,193.95,18,,,percent of total billed charges,pays at 18% of total charges,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,538.74,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,808.11,75,,,percent of total billed charges,75% of total billed charges,538.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,861.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,646.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,824.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,754.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,646.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,409.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,754.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1077.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,969.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.84,1077.48,
TUBE FEEDING PEDI,3752640,CDM,272,RC,,,Outpatient,,,11.5,6.9,,2.07,18,,,percent of total billed charges,pays at 18% of total charges,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.75,50,,,percent of total billed charges,pays at 50% of total billed charges,8.05,70,,,percent of total billed charges,70% of total billed charges,8.63,75,,,percent of total billed charges,75% of total billed charges,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,11.5,
BAG DRAIN URINEMETER,3752760,CDM,272,RC,,,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
SYSTEM-CO-SET DELIVERY,3753190,CDM,272,RC,,,Outpatient,,,272,163.2,,48.96,18,,,percent of total billed charges,pays at 18% of total charges,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136,50,,,percent of total billed charges,pays at 50% of total billed charges,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,136,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,272,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,272,
TRANSDUCER DISP,3753297,CDM,272,RC,,,Outpatient,,,92.5,55.5,,16.65,18,,,percent of total billed charges,pays at 18% of total charges,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.25,50,,,percent of total billed charges,pays at 50% of total billed charges,64.75,70,,,percent of total billed charges,70% of total billed charges,69.38,75,,,percent of total billed charges,75% of total billed charges,46.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,92.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,83.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.49,92.5,
TRAY-AMNIOCENTESIS,3753315,CDM,272,RC,,,Outpatient,,,86,51.6,,15.48,18,,,percent of total billed charges,pays at 18% of total charges,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43,50,,,percent of total billed charges,pays at 50% of total billed charges,60.2,70,,,percent of total billed charges,70% of total billed charges,64.5,75,,,percent of total billed charges,75% of total billed charges,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,86,
TRAY-BIOPSY BN MRW JAMSHI,3753325,CDM,272,RC,,,Outpatient,,,274,164.4,,49.32,18,,,percent of total billed charges,pays at 18% of total charges,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,50,,,percent of total billed charges,pays at 50% of total billed charges,191.8,70,,,percent of total billed charges,70% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,137,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,274,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,274,
TRAY-EPIDURAL,3753335,CDM,272,RC,,,Outpatient,,,175.5,105.3,,31.59,18,,,percent of total billed charges,pays at 18% of total charges,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.75,50,,,percent of total billed charges,pays at 50% of total billed charges,122.85,70,,,percent of total billed charges,70% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,87.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,175.5,
TUBE GASTRIC,3753370,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
TRAY-INCISION & DRAINAGE,3753390,CDM,272,RC,,,Outpatient,,,62,37.2,,11.16,18,,,percent of total billed charges,pays at 18% of total charges,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,62,
TRAY-LMBR PUNC 1032 ADULT,3753410,CDM,272,RC,,,Outpatient,,,147,88.2,,26.46,18,,,percent of total billed charges,pays at 18% of total charges,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.5,50,,,percent of total billed charges,pays at 50% of total billed charges,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,73.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,147,
TRAY-PARACERVCL PUDNL BLK,3753470,CDM,272,RC,,,Outpatient,,,117.5,70.5,,21.15,18,,,percent of total billed charges,pays at 18% of total charges,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.75,50,,,percent of total billed charges,pays at 50% of total billed charges,82.25,70,,,percent of total billed charges,70% of total billed charges,88.13,75,,,percent of total billed charges,75% of total billed charges,58.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.41,117.5,
TRAY THORACENTISIS,3753550,CDM,272,RC,,,Outpatient,,,117.5,70.5,,21.15,18,,,percent of total billed charges,pays at 18% of total charges,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.75,50,,,percent of total billed charges,pays at 50% of total billed charges,82.25,70,,,percent of total billed charges,70% of total billed charges,88.13,75,,,percent of total billed charges,75% of total billed charges,58.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.41,117.5,
TUBE NG SUMP,3753830,CDM,272,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
KIT CENTRAL LINE INSERTI,3754105,CDM,272,RC,,,Outpatient,,,428.5,257.1,,77.13,18,,,percent of total billed charges,pays at 18% of total charges,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.25,50,,,percent of total billed charges,pays at 50% of total billed charges,299.95,70,,,percent of total billed charges,70% of total billed charges,321.38,75,,,percent of total billed charges,75% of total billed charges,214.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,342.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,327.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,299.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,428.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,385.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.15,428.5,
CATH-SG THERMODILUTN 7FR,3754118,CDM,272,RC,,,Outpatient,,,658.5,395.1,,118.53,18,,,percent of total billed charges,pays at 18% of total charges,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,329.25,50,,,percent of total billed charges,pays at 50% of total billed charges,460.95,70,,,percent of total billed charges,70% of total billed charges,493.88,75,,,percent of total billed charges,75% of total billed charges,329.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,526.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,395.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,503.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,460.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,395.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,460.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,658.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,592.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.19,658.5,
GRIPPER NEEDLE ALL SIZES,3754175,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
TRAY-PERICARDIOCENTESIS,3754240,CDM,272,RC,,,Outpatient,,,539.5,323.7,,97.11,18,,,percent of total billed charges,pays at 18% of total charges,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.75,50,,,percent of total billed charges,pays at 50% of total billed charges,377.65,70,,,percent of total billed charges,70% of total billed charges,404.63,75,,,percent of total billed charges,75% of total billed charges,269.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,377.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,323.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,377.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,539.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,485.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.54,539.5,
KIT CENTESIS DRAINAGE,3754242,CDM,272,RC,,,Outpatient,,,906,543.6,,163.08,18,,,percent of total billed charges,pays at 18% of total charges,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,453,50,,,percent of total billed charges,pays at 50% of total billed charges,634.2,70,,,percent of total billed charges,70% of total billed charges,679.5,75,,,percent of total billed charges,75% of total billed charges,453,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,724.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,543.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,693.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,634.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,906,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,815.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.97,906,
AIRCAST SPORT STIRRUP,3754350,CDM,274,RC,L4350,HCPCS,Outpatient,,,87,52.2,,348.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,177.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.03,350,,,Fee Schedule,350% of CMS OPPS Rate,100.55,102,,,Fee Schedule,102% of CMS OPPS Rate,87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,87,230,,,Fee Schedule,230% of CMS OPPS Rate,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,13.63,348.97,
"BELT-PELVIC UNIVERS 10""",3754510,CDM,271,RC,,,Outpatient,,,176.5,105.9,,31.77,18,,,percent of total billed charges,pays at 18% of total charges,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.25,50,,,percent of total billed charges,pays at 50% of total billed charges,123.55,70,,,percent of total billed charges,70% of total billed charges,132.38,75,,,percent of total billed charges,75% of total billed charges,88.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,123.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,176.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,158.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,176.5,
"BELT-PELVIC UNIVERS 10""",3754511,CDM,271,RC,,,Outpatient,,,176.5,105.9,,31.77,18,,,percent of total billed charges,pays at 18% of total charges,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.25,50,,,percent of total billed charges,pays at 50% of total billed charges,123.55,70,,,percent of total billed charges,70% of total billed charges,132.38,75,,,percent of total billed charges,75% of total billed charges,88.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,123.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,176.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,158.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,176.5,
CATH-INTRA-AORT-BAL-9.5,3755121,CDM,272,RC,,,Outpatient,,,3977.5,2386.5,,715.95,18,,,percent of total billed charges,pays at 18% of total charges,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,715.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1988.75,50,,,percent of total billed charges,pays at 50% of total billed charges,2784.25,70,,,percent of total billed charges,70% of total billed charges,2983.13,75,,,percent of total billed charges,75% of total billed charges,1988.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3182,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3042.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1789.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2784.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2386.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1511.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2784.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1909.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3977.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3579.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,623.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.27,3977.5,
REMOVER SKIN STAPLE,3755200,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
TRAY SUTURE DISP,3755202,CDM,272,RC,,,Outpatient,,,12.2,7.32,,2.2,18,,,percent of total billed charges,pays at 18% of total charges,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.1,50,,,percent of total billed charges,pays at 50% of total billed charges,8.54,70,,,percent of total billed charges,70% of total billed charges,9.15,75,,,percent of total billed charges,75% of total billed charges,6.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.91,12.2,
STAPLER 35W PREM,3755225,CDM,272,RC,,,Outpatient,,,80,48,,14.4,18,,,percent of total billed charges,pays at 18% of total charges,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
TRACH SPEAKING VALVE,3755390,CDM,272,RC,,,Outpatient,,,190,114,,34.2,18,,,percent of total billed charges,pays at 18% of total charges,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95,50,,,percent of total billed charges,pays at 50% of total billed charges,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,190,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,190,
TUBE-TRACH BIVONA 7,3755392,CDM,272,RC,,,Outpatient,,,201.5,120.9,,36.27,18,,,percent of total billed charges,pays at 18% of total charges,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.75,50,,,percent of total billed charges,pays at 50% of total billed charges,141.05,70,,,percent of total billed charges,70% of total billed charges,151.13,75,,,percent of total billed charges,75% of total billed charges,100.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,201.5,
TRACH TUBE BIVONA FLEXTEND,3755392,CDM,272,RC,,,Outpatient,,,330.75,198.45,,59.54,18,,,percent of total billed charges,pays at 18% of total charges,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.38,50,,,percent of total billed charges,pays at 50% of total billed charges,231.53,70,,,percent of total billed charges,70% of total billed charges,248.06,75,,,percent of total billed charges,75% of total billed charges,165.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,231.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,330.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,297.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.83,330.75,
DRESSING DUODERM,3756025,CDM,272,RC,,,Outpatient,,,77.5,46.5,,13.95,18,,,percent of total billed charges,pays at 18% of total charges,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.75,50,,,percent of total billed charges,pays at 50% of total billed charges,54.25,70,,,percent of total billed charges,70% of total billed charges,58.13,75,,,percent of total billed charges,75% of total billed charges,38.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,69.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.14,77.5,
BARD FECAL INC,3756152,CDM,272,RC,,,Outpatient,,,67,40.2,,12.06,18,,,percent of total billed charges,pays at 18% of total charges,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.5,50,,,percent of total billed charges,pays at 50% of total billed charges,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,33.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,67,
PEDI PICC INSERTION OUTPT ONLY,3756568,CDM,761,RC,36568,HCPCS,Outpatient,,,1130.4,678.24,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1130.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1130.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,847.8,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,904.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1130.4,103,,,Fee Schedule,103% of CMS OPPS Rate,864.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,508.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,791.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,429.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,791.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,542.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1130.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1017.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1130.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,429.55,4788.21,
PICC INSERTION OUTPT ONLY,3756569,CDM,761,RC,36569,HCPCS,Outpatient,,,1319,791.4,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1319,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1319,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,989.25,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1055.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1319,103,,,Fee Schedule,103% of CMS OPPS Rate,1009.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,593.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,923.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,791.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,501.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,923.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,633.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1319,100,,,Fee Schedule,100% of CMS OPPS Rate,1187.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1319,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,501.22,4788.21,
CUSHION WHEELCHAIR,3757230,CDM,272,RC,,,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.5,50,,,percent of total billed charges,pays at 50% of total billed charges,86.1,70,,,percent of total billed charges,70% of total billed charges,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.27,123,
WOUND VAC GEL CANISTER,3758055,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
WOUND VAC LARGE DSG,3758056,CDM,272,RC,,,Outpatient,,,133.5,80.1,,24.03,18,,,percent of total billed charges,pays at 18% of total charges,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.75,50,,,percent of total billed charges,pays at 50% of total billed charges,93.45,70,,,percent of total billed charges,70% of total billed charges,100.13,75,,,percent of total billed charges,75% of total billed charges,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,133.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,133.5,
WOUND VAC MEDIUM DSG,3758057,CDM,272,RC,,,Outpatient,,,86,51.6,,15.48,18,,,percent of total billed charges,pays at 18% of total charges,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43,50,,,percent of total billed charges,pays at 50% of total billed charges,60.2,70,,,percent of total billed charges,70% of total billed charges,64.5,75,,,percent of total billed charges,75% of total billed charges,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,86,
WOUND VAC SMALL DSG,3758058,CDM,272,RC,,,Outpatient,,,79,47.4,,14.22,18,,,percent of total billed charges,pays at 18% of total charges,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.5,50,,,percent of total billed charges,pays at 50% of total billed charges,55.3,70,,,percent of total billed charges,70% of total billed charges,59.25,75,,,percent of total billed charges,75% of total billed charges,39.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,79,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,79,
SALINE FLUSH PREFILLED SYRINGE,3758100,CDM,272,RC,,,Outpatient,,,15,9,,2.7,18,,,percent of total billed charges,pays at 18% of total charges,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10.5,70,,,percent of total billed charges,70% of total billed charges,11.25,75,,,percent of total billed charges,75% of total billed charges,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,15,
WOUND VAC INCISION MNGMT SYSTM <= 50 CM,3758105,CDM,272,RC,97607,HCPCS,Outpatient,,,865,519,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,605.5,70,,,percent of total billed charges,70% of total billed charges,648.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,692,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,661.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,389.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,519,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,328.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,415.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,778.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,135.55,1200.6,
WOUND VAC INCSN MNGMT SYSM DRESSING ONLY,3758106,CDM,272,RC,G0456,HCPCS,Outpatient,,,492.7,295.62,,88.69,18,,,percent of total billed charges,pays at 18% of total charges,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246.35,50,,,percent of total billed charges,pays at 50% of total billed charges,344.89,70,,,percent of total billed charges,70% of total billed charges,369.53,75,,,percent of total billed charges,75% of total billed charges,246.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,394.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,295.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,344.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,344.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,492.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,443.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.21,492.7,
WOUND VAC INCISION MGMT SYSTM LONG > 50,3758110,CDM,272,RC,97608,HCPCS,Outpatient,,,774,464.4,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,541.8,70,,,percent of total billed charges,70% of total billed charges,580.5,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,619.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,592.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,348.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,541.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,464.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,294.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,541.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,371.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,696.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,121.29,1200.6,
PROSTHETIC SOCK,3758470,CDM,274,RC,L8470,HCPCS,Outpatient,,,18.8,11.28,,32.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.4,50,,,percent of total billed charges,pays at 50% of total billed charges,13.16,70,,,percent of total billed charges,70% of total billed charges,14.1,75,,,percent of total billed charges,75% of total billed charges,16.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,15.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.99,350,,,Fee Schedule,350% of CMS OPPS Rate,9.32,102,,,Fee Schedule,102% of CMS OPPS Rate,18.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,8.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.14,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,7.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.14,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,18.8,230,,,Fee Schedule,230% of CMS OPPS Rate,9.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,9.14,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2.95,32.36,
PAD-CPM,3758500,CDM,272,RC,,,Outpatient,,,346.5,207.9,,62.37,18,,,percent of total billed charges,pays at 18% of total charges,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.25,50,,,percent of total billed charges,pays at 50% of total billed charges,242.55,70,,,percent of total billed charges,70% of total billed charges,259.88,75,,,percent of total billed charges,75% of total billed charges,173.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,277.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,207.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,242.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,242.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,346.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,311.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.3,346.5,
SENSOR CARDIAC OUTPUT NON-INVASIVE,3758502,CDM,272,RC,,,Outpatient,,,255,153,,45.9,18,,,percent of total billed charges,pays at 18% of total charges,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.5,50,,,percent of total billed charges,pays at 50% of total billed charges,178.5,70,,,percent of total billed charges,70% of total billed charges,191.25,75,,,percent of total billed charges,75% of total billed charges,127.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,255,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,229.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.96,255,
PRESSURE BAGS,3758506,CDM,270,RC,,,Outpatient,,,104,62.4,,18.72,18,,,percent of total billed charges,pays at 18% of total charges,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52,50,,,percent of total billed charges,pays at 50% of total billed charges,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,104,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,104,
TRAY INTUBATION,3759305,CDM,272,RC,,,Outpatient,,,201.5,120.9,,36.27,18,,,percent of total billed charges,pays at 18% of total charges,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.75,50,,,percent of total billed charges,pays at 50% of total billed charges,141.05,70,,,percent of total billed charges,70% of total billed charges,151.13,75,,,percent of total billed charges,75% of total billed charges,100.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,161.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,181.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.58,201.5,
THORA-LUMB FLEX SUPPORT PANEL,3759696,CDM,272,RC,L0456,HCPCS,Outpatient,,,1055,633,,4059.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1146.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1146.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,527.5,50,,,percent of total billed charges,pays at 50% of total billed charges,738.5,70,,,percent of total billed charges,70% of total billed charges,791.25,75,,,percent of total billed charges,75% of total billed charges,2063.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,844,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4013.28,350,,,Fee Schedule,350% of CMS OPPS Rate,1169.58,102,,,Fee Schedule,102% of CMS OPPS Rate,807.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,474.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,738.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,633,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1146.65,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,400.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,738.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1146.65,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1055,230,,,Fee Schedule,230% of CMS OPPS Rate,506.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1146.65,100,,,Fee Schedule,100% of CMS OPPS Rate,949.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1146.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.32,4059.14,
SOFT CERVICAL COLLAR,3759700,CDM,274,RC,L0120,HCPCS,Outpatient,,,177.5,106.5,,100.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.75,50,,,percent of total billed charges,pays at 50% of total billed charges,124.25,70,,,percent of total billed charges,70% of total billed charges,133.13,75,,,percent of total billed charges,75% of total billed charges,51.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,142,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.61,350,,,Fee Schedule,350% of CMS OPPS Rate,29.03,102,,,Fee Schedule,102% of CMS OPPS Rate,177.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,79.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,67.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,65.46,230,,,Fee Schedule,230% of CMS OPPS Rate,85.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,177.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,27.81,177.5,
COLLAR CERVICAL /W THORACIC EXT,3759702,CDM,274,RC,L0200,HCPCS,Outpatient,,,524,314.4,,2260.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,638.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,262,50,,,percent of total billed charges,pays at 50% of total billed charges,366.8,70,,,percent of total billed charges,70% of total billed charges,393,75,,,percent of total billed charges,75% of total billed charges,1149.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,419.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2235.35,350,,,Fee Schedule,350% of CMS OPPS Rate,651.44,102,,,Fee Schedule,102% of CMS OPPS Rate,524,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,235.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,366.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,314.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,638.67,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,199.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,366.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,638.67,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,524,230,,,Fee Schedule,230% of CMS OPPS Rate,251.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,638.67,100,,,Fee Schedule,100% of CMS OPPS Rate,524,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,638.67,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,82.11,2260.89,
COLLAR CERVICAL SEMI-RIGID 2PC,3759703,CDM,274,RC,L0172,HCPCS,Outpatient,,,143.5,86.1,,535,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,151.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.75,50,,,percent of total billed charges,pays at 50% of total billed charges,100.45,70,,,percent of total billed charges,70% of total billed charges,107.63,75,,,percent of total billed charges,75% of total billed charges,272.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,528.96,350,,,Fee Schedule,350% of CMS OPPS Rate,154.15,102,,,Fee Schedule,102% of CMS OPPS Rate,143.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,64.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,151.13,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,54.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.13,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,143.5,230,,,Fee Schedule,230% of CMS OPPS Rate,68.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151.13,100,,,Fee Schedule,100% of CMS OPPS Rate,143.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,151.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,22.49,535,
COLLAR CERVICAL MOLDED CUSTOM,3759705,CDM,274,RC,L0170,HCPCS,Outpatient,,,784,470.4,,2596.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,733.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,733.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,392,50,,,percent of total billed charges,pays at 50% of total billed charges,548.8,70,,,percent of total billed charges,70% of total billed charges,588,75,,,percent of total billed charges,75% of total billed charges,1320.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,627.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2567.15,350,,,Fee Schedule,350% of CMS OPPS Rate,748.14,102,,,Fee Schedule,102% of CMS OPPS Rate,784,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,352.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,548.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,470.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,733.47,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,297.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,548.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,733.47,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,784,230,,,Fee Schedule,230% of CMS OPPS Rate,376.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,733.47,100,,,Fee Schedule,100% of CMS OPPS Rate,784,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,733.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,122.85,2596.48,
SACROCOCCYX SHIELD,3759706,CDM,274,RC,L0454,HCPCS,Outpatient,,,378.5,227.1,,1415.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,399.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.25,50,,,percent of total billed charges,pays at 50% of total billed charges,264.95,70,,,percent of total billed charges,70% of total billed charges,283.88,75,,,percent of total billed charges,75% of total billed charges,719.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,302.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1399.48,350,,,Fee Schedule,350% of CMS OPPS Rate,407.85,102,,,Fee Schedule,102% of CMS OPPS Rate,378.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,170.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,264.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,399.85,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,143.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,264.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,399.85,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,378.5,230,,,Fee Schedule,230% of CMS OPPS Rate,181.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,399.85,100,,,Fee Schedule,100% of CMS OPPS Rate,378.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,399.85,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,59.31,1415.47,
CORSET LSO,3759707,CDM,274,RC,L0627,HCPCS,Outpatient,,,449,269.4,,1677.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,473.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,224.5,50,,,percent of total billed charges,pays at 50% of total billed charges,314.3,70,,,percent of total billed charges,70% of total billed charges,336.75,75,,,percent of total billed charges,75% of total billed charges,853.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,359.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1658.76,350,,,Fee Schedule,350% of CMS OPPS Rate,483.41,102,,,Fee Schedule,102% of CMS OPPS Rate,449,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,202.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,314.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,473.93,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,170.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,314.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,473.93,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,449,230,,,Fee Schedule,230% of CMS OPPS Rate,215.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,473.93,100,,,Fee Schedule,100% of CMS OPPS Rate,449,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,473.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.36,1677.71,
BRACE BACK TLSO,3759708,CDM,274,RC,L0486,HCPCS,Outpatient,,,1858,1114.8,,7279.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2056.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2056.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,929,50,,,percent of total billed charges,pays at 50% of total billed charges,1300.6,70,,,percent of total billed charges,70% of total billed charges,1393.5,75,,,percent of total billed charges,75% of total billed charges,3701.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1486.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7197.09,350,,,Fee Schedule,350% of CMS OPPS Rate,2097.44,102,,,Fee Schedule,102% of CMS OPPS Rate,1858,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,320.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,836.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1300.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1114.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2056.31,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,706.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1300.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2056.31,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1858,230,,,Fee Schedule,230% of CMS OPPS Rate,891.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2056.31,100,,,Fee Schedule,100% of CMS OPPS Rate,1858,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2056.31,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,291.15,7279.34,
BRACE TRIPLANAR TLSO,3759709,CDM,274,RC,L0470,HCPCS,Outpatient,,,1030,618,,2420.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,683.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515,50,,,percent of total billed charges,pays at 50% of total billed charges,721,70,,,percent of total billed charges,70% of total billed charges,772.5,75,,,percent of total billed charges,75% of total billed charges,1230.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,824,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2392.78,350,,,Fee Schedule,350% of CMS OPPS Rate,697.32,102,,,Fee Schedule,102% of CMS OPPS Rate,1030,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,463.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,721,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,618,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,683.65,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,391.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,721,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,683.65,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1030,230,,,Fee Schedule,230% of CMS OPPS Rate,494.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,683.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1030,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.65,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,161.4,2420.12,
ABDOMINAL BINDER,3759710,CDM,270,RC,,,Outpatient,,,240.5,144.3,,43.29,18,,,percent of total billed charges,pays at 18% of total charges,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.25,50,,,percent of total billed charges,pays at 50% of total billed charges,168.35,70,,,percent of total billed charges,70% of total billed charges,180.38,75,,,percent of total billed charges,75% of total billed charges,120.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,216.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.69,240.5,
BRACE SAGITTAL CORONAL TLSO,3759711,CDM,274,RC,L0468,HCPCS,Outpatient,,,800.8,480.48,,1881.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,531.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,531.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,400.4,50,,,percent of total billed charges,pays at 50% of total billed charges,560.56,70,,,percent of total billed charges,70% of total billed charges,600.6,75,,,percent of total billed charges,75% of total billed charges,956.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,640.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1860.01,350,,,Fee Schedule,350% of CMS OPPS Rate,542.06,102,,,Fee Schedule,102% of CMS OPPS Rate,800.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,360.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,531.43,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,304.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,560.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,531.43,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,800.8,230,,,Fee Schedule,230% of CMS OPPS Rate,384.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,531.43,100,,,Fee Schedule,100% of CMS OPPS Rate,800.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,531.43,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,125.49,1881.26,
LSO FLEXIBLE,3759712,CDM,274,RC,L0628,HCPCS,Outpatient,,,121.07,72.64,,249.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60.54,50,,,percent of total billed charges,pays at 50% of total billed charges,84.75,70,,,percent of total billed charges,70% of total billed charges,90.8,75,,,percent of total billed charges,75% of total billed charges,126.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,350,,,Fee Schedule,350% of CMS OPPS Rate,71.79,102,,,Fee Schedule,102% of CMS OPPS Rate,121.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,54.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,70.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,46.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,84.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,121.07,230,,,Fee Schedule,230% of CMS OPPS Rate,58.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70.38,100,,,Fee Schedule,100% of CMS OPPS Rate,121.07,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,18.97,249.15,
CTLSO ANT/ POST/ LAT CNTRL W INTERFACE,3759715,CDM,274,RC,L0710,HCPCS,Outpatient,,,2570,1542,,8391.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2370.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2370.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1285,50,,,percent of total billed charges,pays at 50% of total billed charges,1799,70,,,percent of total billed charges,70% of total billed charges,1927.5,75,,,percent of total billed charges,75% of total billed charges,4266.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2056,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8296.75,350,,,Fee Schedule,350% of CMS OPPS Rate,2417.91,102,,,Fee Schedule,102% of CMS OPPS Rate,2570,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,442.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1156.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1799,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1542,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2370.5,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,976.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1799,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2370.5,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,2570,230,,,Fee Schedule,230% of CMS OPPS Rate,1233.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2370.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2570,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,402.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2370.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,402.72,8391.57,
BACK FRAME RIGID W APRON,3759717,CDM,274,RC,L0633,HCPCS,Outpatient,,,313,187.8,,1170.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,330.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,156.5,50,,,percent of total billed charges,pays at 50% of total billed charges,219.1,70,,,percent of total billed charges,70% of total billed charges,234.75,75,,,percent of total billed charges,75% of total billed charges,595.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1157.17,350,,,Fee Schedule,350% of CMS OPPS Rate,337.23,102,,,Fee Schedule,102% of CMS OPPS Rate,313,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,219.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,330.62,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,118.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,219.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330.62,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,313,230,,,Fee Schedule,230% of CMS OPPS Rate,150.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,330.62,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,330.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,49.05,1170.39,
LSO SAGITTAL CORONAL CUSTOM,3759718,CDM,274,RC,L0638,HCPCS,Outpatient,,,1625.47,975.28,,5382.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1520.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1520.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,812.74,50,,,percent of total billed charges,pays at 50% of total billed charges,1137.83,70,,,percent of total billed charges,70% of total billed charges,1219.1,75,,,percent of total billed charges,75% of total billed charges,2737.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1300.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5322.03,350,,,Fee Schedule,350% of CMS OPPS Rate,1550.99,102,,,Fee Schedule,102% of CMS OPPS Rate,1625.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,280.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,731.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1137.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1520.58,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,617.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1137.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1520.58,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1625.47,230,,,Fee Schedule,230% of CMS OPPS Rate,780.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1520.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1625.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1520.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,254.71,5382.85,
ORTHOSIS INTERFACE SOCK,3759720,CDM,274,RC,L3995,HCPCS,Outpatient,,,78,46.8,,158.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39,50,,,percent of total billed charges,pays at 50% of total billed charges,54.6,70,,,percent of total billed charges,70% of total billed charges,58.5,75,,,percent of total billed charges,75% of total billed charges,80.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.59,350,,,Fee Schedule,350% of CMS OPPS Rate,45.63,102,,,Fee Schedule,102% of CMS OPPS Rate,78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,35.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,44.74,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,29.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.74,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,78,230,,,Fee Schedule,230% of CMS OPPS Rate,37.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,44.74,100,,,Fee Schedule,100% of CMS OPPS Rate,78,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,12.22,158.38,
HUMERAL ORTHOSIS,3759721,CDM,274,RC,L3980,HCPCS,Outpatient,,,377.4,226.44,,1367.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,386.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.7,50,,,percent of total billed charges,pays at 50% of total billed charges,264.18,70,,,percent of total billed charges,70% of total billed charges,283.05,75,,,percent of total billed charges,75% of total billed charges,695.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,301.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1351.95,350,,,Fee Schedule,350% of CMS OPPS Rate,394,102,,,Fee Schedule,102% of CMS OPPS Rate,377.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,169.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,264.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,386.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,143.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,264.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,377.4,230,,,Fee Schedule,230% of CMS OPPS Rate,181.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,386.27,100,,,Fee Schedule,100% of CMS OPPS Rate,377.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,386.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,59.14,1367.4,
ANKLE FOOT ORTHOTIC PLASTIC,3759723,CDM,274,RC,L1960,HCPCS,Outpatient,,,488,292.8,,2104.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,594.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,244,50,,,percent of total billed charges,pays at 50% of total billed charges,341.6,70,,,percent of total billed charges,70% of total billed charges,366,75,,,percent of total billed charges,75% of total billed charges,1069.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,390.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080.3,350,,,Fee Schedule,350% of CMS OPPS Rate,606.26,102,,,Fee Schedule,102% of CMS OPPS Rate,488,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,219.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,594.37,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,185.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,341.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,594.37,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,488,230,,,Fee Schedule,230% of CMS OPPS Rate,234.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,594.37,100,,,Fee Schedule,100% of CMS OPPS Rate,488,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.37,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,76.47,2104.07,
ANKLE FOOT ORTHOTIC ARTICULATED,3759724,CDM,274,RC,L1970,HCPCS,Outpatient,,,722.5,433.5,,2701.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,763.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,763.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,361.25,50,,,percent of total billed charges,pays at 50% of total billed charges,505.75,70,,,percent of total billed charges,70% of total billed charges,541.88,75,,,percent of total billed charges,75% of total billed charges,1373.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,578,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2670.57,350,,,Fee Schedule,350% of CMS OPPS Rate,778.28,102,,,Fee Schedule,102% of CMS OPPS Rate,722.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,325.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,505.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,433.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,763.02,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,274.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,505.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,763.02,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,722.5,230,,,Fee Schedule,230% of CMS OPPS Rate,346.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,763.02,100,,,Fee Schedule,100% of CMS OPPS Rate,722.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,763.02,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,113.22,2701.09,
ANKLE FOOT ORTHOTIC,3759725,CDM,274,RC,L1945,HCPCS,Outpatient,,,1077,646.2,,3513.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,992.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,538.5,50,,,percent of total billed charges,pays at 50% of total billed charges,753.9,70,,,percent of total billed charges,70% of total billed charges,807.75,75,,,percent of total billed charges,75% of total billed charges,1786.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,861.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3474.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1012.47,102,,,Fee Schedule,102% of CMS OPPS Rate,1077,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,185.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,484.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,753.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,646.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,992.62,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,409.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,753.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,992.62,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1077,230,,,Fee Schedule,230% of CMS OPPS Rate,516.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,992.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1077,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,168.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,992.62,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,168.77,3513.87,
ANKLE FOOT ORTHOTIC,3759726,CDM,274,RC,L1906,HCPCS,Outpatient,,,136.5,81.9,,456.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.25,50,,,percent of total billed charges,pays at 50% of total billed charges,95.55,70,,,percent of total billed charges,70% of total billed charges,102.38,75,,,percent of total billed charges,75% of total billed charges,232.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,451.36,350,,,Fee Schedule,350% of CMS OPPS Rate,131.54,102,,,Fee Schedule,102% of CMS OPPS Rate,136.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,61.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,51.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,136.5,230,,,Fee Schedule,230% of CMS OPPS Rate,65.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,100% of CMS OPPS Rate,136.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,21.39,456.52,
FOOT DROP POSITIONING DEVICE,3759731,CDM,274,RC,L4398,HCPCS,Outpatient,,,111.51,66.91,,315.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.76,50,,,percent of total billed charges,pays at 50% of total billed charges,78.06,70,,,percent of total billed charges,70% of total billed charges,83.63,75,,,percent of total billed charges,75% of total billed charges,160.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.75,350,,,Fee Schedule,350% of CMS OPPS Rate,90.85,102,,,Fee Schedule,102% of CMS OPPS Rate,111.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.07,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,42.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.07,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,111.51,230,,,Fee Schedule,230% of CMS OPPS Rate,53.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.07,100,,,Fee Schedule,100% of CMS OPPS Rate,111.51,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.07,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,17.47,315.31,
COLLAR CERVICAL ADJ,3759732,CDM,274,RC,L0180,HCPCS,Outpatient,,,418,250.8,,1562.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,441.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209,50,,,percent of total billed charges,pays at 50% of total billed charges,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,794.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1544.83,350,,,Fee Schedule,350% of CMS OPPS Rate,450.21,102,,,Fee Schedule,102% of CMS OPPS Rate,418,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,158.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,418,230,,,Fee Schedule,230% of CMS OPPS Rate,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,100% of CMS OPPS Rate,418,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,65.5,1562.49,
VARUS/VALGUS T-STRAP DEVICE,3759733,CDM,274,RC,L2270,HCPCS,Outpatient,,,64,38.4,,203.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32,50,,,percent of total billed charges,pays at 50% of total billed charges,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,103.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.57,350,,,Fee Schedule,350% of CMS OPPS Rate,58.74,102,,,Fee Schedule,102% of CMS OPPS Rate,64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,57.59,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,24.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.59,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,64,230,,,Fee Schedule,230% of CMS OPPS Rate,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57.59,100,,,Fee Schedule,100% of CMS OPPS Rate,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,57.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,10.03,203.87,
VARUS/VALGUS PLSTC CRRCTN,3759736,CDM,274,RC,L2275,HCPCS,Outpatient,,,133,79.8,,495.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,140.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.5,50,,,percent of total billed charges,pays at 50% of total billed charges,93.1,70,,,percent of total billed charges,70% of total billed charges,99.75,75,,,percent of total billed charges,75% of total billed charges,252.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,106.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.35,350,,,Fee Schedule,350% of CMS OPPS Rate,142.9,102,,,Fee Schedule,102% of CMS OPPS Rate,133,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,59.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,140.1,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,50.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.1,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,133,230,,,Fee Schedule,230% of CMS OPPS Rate,63.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.1,100,,,Fee Schedule,100% of CMS OPPS Rate,133,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.1,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,20.84,495.95,
FOOT ARCH SUPPORT INSERT,3759737,CDM,274,RC,L3010,HCPCS,Outpatient,,,247.77,148.66,,711.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,200.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.89,50,,,percent of total billed charges,pays at 50% of total billed charges,173.44,70,,,percent of total billed charges,70% of total billed charges,185.83,75,,,percent of total billed charges,75% of total billed charges,361.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,198.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,703.12,350,,,Fee Schedule,350% of CMS OPPS Rate,204.91,102,,,Fee Schedule,102% of CMS OPPS Rate,247.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,111.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,200.89,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,94.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.89,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,247.77,230,,,Fee Schedule,230% of CMS OPPS Rate,118.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200.89,100,,,Fee Schedule,100% of CMS OPPS Rate,247.77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,200.89,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,38.83,711.15,
HEEL & SOLE LIFT,3759738,CDM,274,RC,L3310,HCPCS,Outpatient,,,89,53.4,,332.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,93.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.5,50,,,percent of total billed charges,pays at 50% of total billed charges,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,168.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.44,350,,,Fee Schedule,350% of CMS OPPS Rate,95.72,102,,,Fee Schedule,102% of CMS OPPS Rate,89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,93.84,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,33.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.84,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,89,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93.84,100,,,Fee Schedule,100% of CMS OPPS Rate,89,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.84,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,13.95,332.19,
MOLDED INNER BOOT ADD TO LE,3759741,CDM,274,RC,L2280,HCPCS,Outpatient,,,526.8,316.08,,1718.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,485.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.4,50,,,percent of total billed charges,pays at 50% of total billed charges,368.76,70,,,percent of total billed charges,70% of total billed charges,395.1,75,,,percent of total billed charges,75% of total billed charges,873.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,421.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1699.43,350,,,Fee Schedule,350% of CMS OPPS Rate,495.26,102,,,Fee Schedule,102% of CMS OPPS Rate,526.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,237.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,368.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,485.55,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,200.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,368.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,485.55,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,526.8,230,,,Fee Schedule,230% of CMS OPPS Rate,252.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,485.55,100,,,Fee Schedule,100% of CMS OPPS Rate,526.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,485.55,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,82.55,1718.85,
TIBIAL ORTHOTIC,3759742,CDM,274,RC,L2106,HCPCS,Outpatient,,,736.5,441.9,,3176.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,897.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,897.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,368.25,50,,,percent of total billed charges,pays at 50% of total billed charges,515.55,70,,,percent of total billed charges,70% of total billed charges,552.38,75,,,percent of total billed charges,75% of total billed charges,1615.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,589.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3140.62,350,,,Fee Schedule,350% of CMS OPPS Rate,915.27,102,,,Fee Schedule,102% of CMS OPPS Rate,736.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,331.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,515.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,897.32,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,279.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,515.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897.32,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,736.5,230,,,Fee Schedule,230% of CMS OPPS Rate,353.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,897.32,100,,,Fee Schedule,100% of CMS OPPS Rate,736.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,897.32,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,115.41,3176.51,
INSERTS PARTIAL FOOT TOE FILLER,3759743,CDM,274,RC,L5000,HCPCS,Outpatient,,,835.04,501.02,,2724.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,769.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,417.52,50,,,percent of total billed charges,pays at 50% of total billed charges,584.53,70,,,percent of total billed charges,70% of total billed charges,626.28,75,,,percent of total billed charges,75% of total billed charges,1385.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,668.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2693.64,350,,,Fee Schedule,350% of CMS OPPS Rate,785,102,,,Fee Schedule,102% of CMS OPPS Rate,835.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,375.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,584.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,501.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,769.61,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,317.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,584.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,769.61,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,835.04,230,,,Fee Schedule,230% of CMS OPPS Rate,400.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,769.61,100,,,Fee Schedule,100% of CMS OPPS Rate,835.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,769.61,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,130.85,2724.42,
INSERTS DIABETIC SHOE CUSTOM,3759744,CDM,274,RC,A5500,HCPCS,Outpatient,,,105.86,63.52,,299.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,84.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,74.1,70,,,percent of total billed charges,70% of total billed charges,79.4,75,,,percent of total billed charges,75% of total billed charges,152.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296,350,,,Fee Schedule,350% of CMS OPPS Rate,86.26,102,,,Fee Schedule,102% of CMS OPPS Rate,105.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,47.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,84.57,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,40.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.57,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,105.86,230,,,Fee Schedule,230% of CMS OPPS Rate,50.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,84.57,100,,,Fee Schedule,100% of CMS OPPS Rate,105.86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,84.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,16.59,299.38,
PRETIBIAL SHELL ADD TO LE,3759745,CDM,274,RC,L2340,HCPCS,Outpatient,,,644.8,386.88,,2103.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,594.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,322.4,50,,,percent of total billed charges,pays at 50% of total billed charges,451.36,70,,,percent of total billed charges,70% of total billed charges,483.6,75,,,percent of total billed charges,75% of total billed charges,1069.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,515.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2080.05,350,,,Fee Schedule,350% of CMS OPPS Rate,606.19,102,,,Fee Schedule,102% of CMS OPPS Rate,644.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,290.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,451.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,594.3,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,245.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,451.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,594.3,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,644.8,230,,,Fee Schedule,230% of CMS OPPS Rate,309.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,594.3,100,,,Fee Schedule,100% of CMS OPPS Rate,644.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,594.3,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,101.04,2103.82,
INSERTS DIABETIC SHOE,3759747,CDM,274,RC,A5512,HCPCS,Outpatient,,,50.38,30.23,,122.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,35.27,70,,,percent of total billed charges,70% of total billed charges,37.79,75,,,percent of total billed charges,75% of total billed charges,62.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.72,350,,,Fee Schedule,350% of CMS OPPS Rate,35.18,102,,,Fee Schedule,102% of CMS OPPS Rate,50.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,22.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.49,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,19.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.49,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,50.38,230,,,Fee Schedule,230% of CMS OPPS Rate,24.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.49,100,,,Fee Schedule,100% of CMS OPPS Rate,50.38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,34.49,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,7.89,122.09,
BOOT WALKING,3759748,CDM,274,RC,L4360,HCPCS,Outpatient,,,281,168.6,,1051.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,296.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,140.5,50,,,percent of total billed charges,pays at 50% of total billed charges,196.7,70,,,percent of total billed charges,70% of total billed charges,210.75,75,,,percent of total billed charges,75% of total billed charges,534.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1039.19,350,,,Fee Schedule,350% of CMS OPPS Rate,302.85,102,,,Fee Schedule,102% of CMS OPPS Rate,281,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,126.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,296.91,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,106.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.91,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,281,230,,,Fee Schedule,230% of CMS OPPS Rate,134.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,296.91,100,,,Fee Schedule,100% of CMS OPPS Rate,281,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,296.91,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,44.03,1051.06,
SHOE INSERT W ANKLE JOINTS,3759749,CDM,274,RC,L2180,HCPCS,Outpatient,,,198.5,119.1,,592.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,167.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.25,50,,,percent of total billed charges,pays at 50% of total billed charges,138.95,70,,,percent of total billed charges,70% of total billed charges,148.88,75,,,percent of total billed charges,75% of total billed charges,301.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,158.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,586.04,350,,,Fee Schedule,350% of CMS OPPS Rate,170.79,102,,,Fee Schedule,102% of CMS OPPS Rate,198.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,89.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,167.44,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,75.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.44,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,198.5,230,,,Fee Schedule,230% of CMS OPPS Rate,95.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,167.44,100,,,Fee Schedule,100% of CMS OPPS Rate,198.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,167.44,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,31.1,592.74,
PAD HALO REPLACEMENT,3759750,CDM,274,RC,L0861,HCPCS,Outpatient,,,303.5,182.1,,879.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,248.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,151.75,50,,,percent of total billed charges,pays at 50% of total billed charges,212.45,70,,,percent of total billed charges,70% of total billed charges,227.63,75,,,percent of total billed charges,75% of total billed charges,447.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,869.79,350,,,Fee Schedule,350% of CMS OPPS Rate,253.48,102,,,Fee Schedule,102% of CMS OPPS Rate,303.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,136.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,248.51,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,115.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,212.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.51,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,303.5,230,,,Fee Schedule,230% of CMS OPPS Rate,145.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,248.51,100,,,Fee Schedule,100% of CMS OPPS Rate,303.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,248.51,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,47.56,879.73,
BRACE CERVICAL OCCPTL/MANDBLR SUPPRT,3759751,CDM,274,RC,L0180,HCPCS,Outpatient,,,492.5,295.5,,1562.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,441.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,246.25,50,,,percent of total billed charges,pays at 50% of total billed charges,344.75,70,,,percent of total billed charges,70% of total billed charges,369.38,75,,,percent of total billed charges,75% of total billed charges,794.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1544.83,350,,,Fee Schedule,350% of CMS OPPS Rate,450.21,102,,,Fee Schedule,102% of CMS OPPS Rate,492.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,221.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,344.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,187.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,344.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,492.5,230,,,Fee Schedule,230% of CMS OPPS Rate,236.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,100% of CMS OPPS Rate,492.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,441.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,77.17,1562.49,
HALO /W VEST,3759755,CDM,274,RC,L0810,HCPCS,Outpatient,,,2486.65,1491.99,,10396.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2936.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2936.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1243.33,50,,,percent of total billed charges,pays at 50% of total billed charges,1740.66,70,,,percent of total billed charges,70% of total billed charges,1864.99,75,,,percent of total billed charges,75% of total billed charges,5286.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1989.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10278.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2995.49,102,,,Fee Schedule,102% of CMS OPPS Rate,2486.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,428.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1118.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1740.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1491.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2936.75,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,944.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1740.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2936.75,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,2486.65,230,,,Fee Schedule,230% of CMS OPPS Rate,1193.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2936.75,100,,,Fee Schedule,100% of CMS OPPS Rate,2486.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2936.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,389.66,10396.1,
HALO ADDITION MRI COMPATB /W RING/PINS,3759756,CDM,274,RC,L0859,HCPCS,Outpatient,,,1474.8,884.88,,6165.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1741.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1741.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,737.4,50,,,percent of total billed charges,pays at 50% of total billed charges,1032.36,70,,,percent of total billed charges,70% of total billed charges,1106.1,75,,,percent of total billed charges,75% of total billed charges,3135.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1179.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6096.13,350,,,Fee Schedule,350% of CMS OPPS Rate,1776.59,102,,,Fee Schedule,102% of CMS OPPS Rate,1474.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,254.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,663.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1032.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,884.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1741.75,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,560.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1032.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1741.75,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1474.8,230,,,Fee Schedule,230% of CMS OPPS Rate,707.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1741.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1474.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1741.75,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,231.1,6165.8,
HIP ORTHOTIC,3759760,CDM,274,RC,L1686,HCPCS,Outpatient,,,802.5,481.5,,3462.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,978.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,978.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,401.25,50,,,percent of total billed charges,pays at 50% of total billed charges,561.75,70,,,percent of total billed charges,70% of total billed charges,601.88,75,,,percent of total billed charges,75% of total billed charges,1760.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,642,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3423.53,350,,,Fee Schedule,350% of CMS OPPS Rate,997.71,102,,,Fee Schedule,102% of CMS OPPS Rate,802.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,361.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,561.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,481.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,978.15,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,304.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,561.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,978.15,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,802.5,230,,,Fee Schedule,230% of CMS OPPS Rate,385.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,978.15,100,,,Fee Schedule,100% of CMS OPPS Rate,802.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,978.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,125.75,3462.65,
KNEE JOINT DISC DIAL LOCK,3759762,CDM,274,RC,L2425,HCPCS,Outpatient,,,156.5,93.9,,585.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,165.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.25,50,,,percent of total billed charges,pays at 50% of total billed charges,109.55,70,,,percent of total billed charges,70% of total billed charges,117.38,75,,,percent of total billed charges,75% of total billed charges,297.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,125.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,578.45,350,,,Fee Schedule,350% of CMS OPPS Rate,168.58,102,,,Fee Schedule,102% of CMS OPPS Rate,156.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,70.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,59.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,109.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,156.5,230,,,Fee Schedule,230% of CMS OPPS Rate,75.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,100% of CMS OPPS Rate,156.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,24.52,585.06,
PROSTHETIC SHRINKER BELOW KNEE,3759763,CDM,274,RC,L8440,HCPCS,Outpatient,,,71.93,43.16,,178.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.97,50,,,percent of total billed charges,pays at 50% of total billed charges,50.35,70,,,percent of total billed charges,70% of total billed charges,53.95,75,,,percent of total billed charges,75% of total billed charges,90.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,57.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.61,350,,,Fee Schedule,350% of CMS OPPS Rate,51.47,102,,,Fee Schedule,102% of CMS OPPS Rate,71.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,32.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,50.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,27.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,50.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,71.93,230,,,Fee Schedule,230% of CMS OPPS Rate,34.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50.46,100,,,Fee Schedule,100% of CMS OPPS Rate,71.93,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,11.27,178.63,
PELVIC JOINT ORTHOTIC,3759764,CDM,274,RC,L2570,HCPCS,Outpatient,,,559,335.4,,2410.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,681,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,681,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,279.5,50,,,percent of total billed charges,pays at 50% of total billed charges,391.3,70,,,percent of total billed charges,70% of total billed charges,419.25,75,,,percent of total billed charges,75% of total billed charges,1225.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,447.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2383.5,350,,,Fee Schedule,350% of CMS OPPS Rate,694.62,102,,,Fee Schedule,102% of CMS OPPS Rate,559,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,96.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,251.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,391.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,335.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,681,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,212.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,391.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,681,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,559,230,,,Fee Schedule,230% of CMS OPPS Rate,268.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,681,100,,,Fee Schedule,100% of CMS OPPS Rate,559,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,681,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,87.6,2410.74,
KNEE ORTHOTIC DOUBLE UPRIGHT,3759765,CDM,274,RC,L1845,HCPCS,Outpatient,,,834,500.4,,3555.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1004.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,417,50,,,percent of total billed charges,pays at 50% of total billed charges,583.8,70,,,percent of total billed charges,70% of total billed charges,625.5,75,,,percent of total billed charges,75% of total billed charges,1807.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,667.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3515.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1024.47,102,,,Fee Schedule,102% of CMS OPPS Rate,834,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,375.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,316.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,583.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,834,230,,,Fee Schedule,230% of CMS OPPS Rate,400.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,100% of CMS OPPS Rate,834,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,130.69,3555.51,
HEEL BOOTS,3759766,CDM,274,RC,L3260,HCPCS,Outpatient,,,166,99.6,,29.88,18,,,percent of total billed charges,pays at 18% of total charges,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83,50,,,percent of total billed charges,pays at 50% of total billed charges,116.2,70,,,percent of total billed charges,70% of total billed charges,124.5,75,,,percent of total billed charges,75% of total billed charges,83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,166,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.01,166,
PRESSURE RELIEF SHOE,3759767,CDM,274,RC,L2999,HCPCS,Outpatient,,,225,135,,40.5,18,,,percent of total billed charges,pays at 18% of total charges,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.5,50,,,percent of total billed charges,pays at 50% of total billed charges,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,112.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,225,
KNEE ORTHOTIC SINGLE UPRIGHT,3759768,CDM,274,RC,L1844,HCPCS,Outpatient,,,1530.73,918.44,,6334.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1789.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1789.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,765.37,50,,,percent of total billed charges,pays at 50% of total billed charges,1071.51,70,,,percent of total billed charges,70% of total billed charges,1148.05,75,,,percent of total billed charges,75% of total billed charges,3221.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1224.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6263.32,350,,,Fee Schedule,350% of CMS OPPS Rate,1825.31,102,,,Fee Schedule,102% of CMS OPPS Rate,1530.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,263.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,688.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1071.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,918.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1789.52,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,581.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1071.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1789.52,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1530.73,230,,,Fee Schedule,230% of CMS OPPS Rate,734.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1789.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1530.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1789.52,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,239.87,6334.9,
KNEE ORTHOTIC ADJ JOINTS,3759769,CDM,274,RC,L1832,HCPCS,Outpatient,,,697,418.2,,2307.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,651.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,348.5,50,,,percent of total billed charges,pays at 50% of total billed charges,487.9,70,,,percent of total billed charges,70% of total billed charges,522.75,75,,,percent of total billed charges,75% of total billed charges,1173.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,557.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2281.72,350,,,Fee Schedule,350% of CMS OPPS Rate,664.96,102,,,Fee Schedule,102% of CMS OPPS Rate,697,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,313.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,651.92,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,264.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,487.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,651.92,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,697,230,,,Fee Schedule,230% of CMS OPPS Rate,334.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,651.92,100,,,Fee Schedule,100% of CMS OPPS Rate,697,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,651.92,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,109.22,2307.8,
KNEE LOCK BAIL/CABLE OR EQAL ADDITION,3759770,CDM,274,RC,L2415,HCPCS,Outpatient,,,172.75,103.65,,495.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,140.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,86.38,50,,,percent of total billed charges,pays at 50% of total billed charges,120.93,70,,,percent of total billed charges,70% of total billed charges,129.56,75,,,percent of total billed charges,75% of total billed charges,252.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,490.14,350,,,Fee Schedule,350% of CMS OPPS Rate,142.84,102,,,Fee Schedule,102% of CMS OPPS Rate,172.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,77.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,140.04,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,65.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,120.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.04,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,172.75,230,,,Fee Schedule,230% of CMS OPPS Rate,82.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.04,100,,,Fee Schedule,100% of CMS OPPS Rate,172.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,140.04,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,27.07,495.74,
KAFO FEMORAL SOFT,3759771,CDM,274,RC,L2132,HCPCS,Outpatient,,,1043.15,625.89,,3454.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,975.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,975.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,521.58,50,,,percent of total billed charges,pays at 50% of total billed charges,730.21,70,,,percent of total billed charges,70% of total billed charges,782.36,75,,,percent of total billed charges,75% of total billed charges,1756.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,834.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3415.41,350,,,Fee Schedule,350% of CMS OPPS Rate,995.35,102,,,Fee Schedule,102% of CMS OPPS Rate,1043.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,179.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,469.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,730.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,625.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,975.83,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,396.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,730.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975.83,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1043.15,230,,,Fee Schedule,230% of CMS OPPS Rate,500.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,975.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,975.83,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,163.46,3454.44,
KNEE JOINT RATCHET LOCK ADD ON,3759772,CDM,274,RC,L2430,HCPCS,Outpatient,,,203.84,122.3,,585.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,165.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,101.92,50,,,percent of total billed charges,pays at 50% of total billed charges,142.69,70,,,percent of total billed charges,70% of total billed charges,152.88,75,,,percent of total billed charges,75% of total billed charges,297.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,163.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,578.45,350,,,Fee Schedule,350% of CMS OPPS Rate,168.58,102,,,Fee Schedule,102% of CMS OPPS Rate,203.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,77.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,203.84,230,,,Fee Schedule,230% of CMS OPPS Rate,97.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,165.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,31.94,585.06,
RIGID DRESSING,3759773,CDM,274,RC,L5450,HCPCS,Outpatient,,,712,427.2,,2196.78,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,620.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,620.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,356,50,,,percent of total billed charges,pays at 50% of total billed charges,498.4,70,,,percent of total billed charges,70% of total billed charges,534,75,,,percent of total billed charges,75% of total billed charges,1117.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,569.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2171.96,350,,,Fee Schedule,350% of CMS OPPS Rate,632.97,102,,,Fee Schedule,102% of CMS OPPS Rate,712,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,320.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,498.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,620.56,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,270.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,498.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,620.56,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,712,230,,,Fee Schedule,230% of CMS OPPS Rate,341.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,620.56,100,,,Fee Schedule,100% of CMS OPPS Rate,712,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,620.56,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,111.57,2196.78,
KAFO ORTHOSIS DOUBLE UPRIGHT,3759774,CDM,274,RC,L2036,HCPCS,Outpatient,,,2234.7,1340.82,,7400.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2090.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2090.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1117.35,50,,,percent of total billed charges,pays at 50% of total billed charges,1564.29,70,,,percent of total billed charges,70% of total billed charges,1676.03,75,,,percent of total billed charges,75% of total billed charges,3762.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1787.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7316.75,350,,,Fee Schedule,350% of CMS OPPS Rate,2132.31,102,,,Fee Schedule,102% of CMS OPPS Rate,2234.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,385.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1005.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1564.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1340.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2090.5,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,849.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1564.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2090.5,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,2234.7,230,,,Fee Schedule,230% of CMS OPPS Rate,1072.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2090.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2234.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,350.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,2090.5,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,350.18,7400.37,
HEEL PROTECTION BOOT,3759775,CDM,270,RC,,,Outpatient,,,69.6,41.76,,12.53,18,,,percent of total billed charges,pays at 18% of total charges,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.8,50,,,percent of total billed charges,pays at 50% of total billed charges,48.72,70,,,percent of total billed charges,70% of total billed charges,52.2,75,,,percent of total billed charges,75% of total billed charges,34.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,55.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,48.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,69.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,62.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.91,69.6,
POSTOP IMMEDIATE FITTING RIGID DRSG,3759776,CDM,274,RC,L5400,HCPCS,Outpatient,,,1750,1050,,5767.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1629.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,875,50,,,percent of total billed charges,pays at 50% of total billed charges,1225,70,,,percent of total billed charges,70% of total billed charges,1312.5,75,,,percent of total billed charges,75% of total billed charges,2932.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5702.38,350,,,Fee Schedule,350% of CMS OPPS Rate,1661.84,102,,,Fee Schedule,102% of CMS OPPS Rate,1750,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,301.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,787.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1225,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1050,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1629.25,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,665,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1225,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1629.25,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1750,230,,,Fee Schedule,230% of CMS OPPS Rate,840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1629.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1750,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1629.25,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,274.23,5767.55,
SUSPENSION SLEEVE,3759778,CDM,274,RC,L5685,HCPCS,Outpatient,,,144.55,86.73,,523.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,147.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.28,50,,,percent of total billed charges,pays at 50% of total billed charges,101.19,70,,,percent of total billed charges,70% of total billed charges,108.41,75,,,percent of total billed charges,75% of total billed charges,266.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.76,350,,,Fee Schedule,350% of CMS OPPS Rate,150.89,102,,,Fee Schedule,102% of CMS OPPS Rate,144.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,65.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,101.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,147.93,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,54.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,101.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.93,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,144.55,230,,,Fee Schedule,230% of CMS OPPS Rate,69.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147.93,100,,,Fee Schedule,100% of CMS OPPS Rate,144.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,147.93,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,22.65,523.67,
AFO ORTHOSIS CUSTOM FAB,3759779,CDM,274,RC,L4631,HCPCS,Outpatient,,,1855.83,1113.5,,6036.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1705.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,927.92,50,,,percent of total billed charges,pays at 50% of total billed charges,1299.08,70,,,percent of total billed charges,70% of total billed charges,1391.87,75,,,percent of total billed charges,75% of total billed charges,3069.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1484.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5968.69,350,,,Fee Schedule,350% of CMS OPPS Rate,1739.45,102,,,Fee Schedule,102% of CMS OPPS Rate,1855.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,319.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,835.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1299.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1113.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1705.34,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,705.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1299.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1705.34,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1855.83,230,,,Fee Schedule,230% of CMS OPPS Rate,890.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1705.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1855.83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1705.34,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,290.81,6036.9,
HIP ORTHOTIC W ADJ FLEX EXTEN,3759784,CDM,274,RC,L2624,HCPCS,Outpatient,,,361,216.6,,1349.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,381.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,381.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,180.5,50,,,percent of total billed charges,pays at 50% of total billed charges,252.7,70,,,percent of total billed charges,70% of total billed charges,270.75,75,,,percent of total billed charges,75% of total billed charges,686.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,288.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1334.48,350,,,Fee Schedule,350% of CMS OPPS Rate,388.91,102,,,Fee Schedule,102% of CMS OPPS Rate,361,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,162.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,381.28,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,137.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,252.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,381.28,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,361,230,,,Fee Schedule,230% of CMS OPPS Rate,173.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,381.28,100,,,Fee Schedule,100% of CMS OPPS Rate,361,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,381.28,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,56.57,1349.73,
MIAMI J CERVICAL COLLAR,3759791,CDM,274,RC,L0174,HCPCS,Outpatient,,,331,198.6,,1042.78,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,165.5,50,,,percent of total billed charges,pays at 50% of total billed charges,231.7,70,,,percent of total billed charges,70% of total billed charges,248.25,75,,,percent of total billed charges,75% of total billed charges,530.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031,350,,,Fee Schedule,350% of CMS OPPS Rate,300.46,102,,,Fee Schedule,102% of CMS OPPS Rate,331,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,148.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.57,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,125.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,231.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.57,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,331,230,,,Fee Schedule,230% of CMS OPPS Rate,158.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.57,100,,,Fee Schedule,100% of CMS OPPS Rate,331,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,294.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,51.87,1042.78,
COMPRESSION STOCKING GRADIENT,3759793,CDM,272,RC,A6530,HCPCS,Outpatient,,,114,68.4,,20.52,18,,,percent of total billed charges,pays at 18% of total charges,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.8,70,,,percent of total billed charges,70% of total billed charges,85.5,75,,,percent of total billed charges,75% of total billed charges,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,79.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,102.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,114,
COMPRESSION STOCKING,3759794,CDM,272,RC,A6531,HCPCS,Outpatient,,,64,38.4,,11.52,18,,,percent of total billed charges,pays at 18% of total charges,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.03,64,
KNEE ORTHOSIS ELASTIC,3759795,CDM,274,RC,L1810,HCPCS,Outpatient,,,112.05,67.23,,406,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,56.03,50,,,percent of total billed charges,pays at 50% of total billed charges,78.44,70,,,percent of total billed charges,70% of total billed charges,84.04,75,,,percent of total billed charges,75% of total billed charges,206.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.42,350,,,Fee Schedule,350% of CMS OPPS Rate,116.98,102,,,Fee Schedule,102% of CMS OPPS Rate,112.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,114.69,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,42.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.69,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,112.05,230,,,Fee Schedule,230% of CMS OPPS Rate,53.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.69,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,17.56,406,
VEST SURGICAL SUPPORT,3759798,CDM,271,RC,,,Outpatient,,,105,63,,18.9,18,,,percent of total billed charges,pays at 18% of total charges,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.5,50,,,percent of total billed charges,pays at 50% of total billed charges,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,52.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,105,
KNEE ORTHOSIS ADD-ON,3759799,CDM,274,RC,L2800,HCPCS,Outpatient,,,112,67.2,,404.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,56,50,,,percent of total billed charges,pays at 50% of total billed charges,78.4,70,,,percent of total billed charges,70% of total billed charges,84,75,,,percent of total billed charges,75% of total billed charges,205.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.33,350,,,Fee Schedule,350% of CMS OPPS Rate,116.67,102,,,Fee Schedule,102% of CMS OPPS Rate,112,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,50.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,114.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,42.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,112,230,,,Fee Schedule,230% of CMS OPPS Rate,53.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.38,100,,,Fee Schedule,100% of CMS OPPS Rate,112,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,114.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,17.55,404.91,
DRSG FOAM W NONADHSV,3759800,CDM,272,RC,,,Outpatient,,,19.6,11.76,,3.53,18,,,percent of total billed charges,pays at 18% of total charges,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.8,50,,,percent of total billed charges,pays at 50% of total billed charges,13.72,70,,,percent of total billed charges,70% of total billed charges,14.7,75,,,percent of total billed charges,75% of total billed charges,9.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.07,19.6,
INCENTIVE SPIROMETER,3759801,CDM,272,RC,,,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
DEVICE VASCLR SECUREMENT PICC,3759802,CDM,272,RC,,,Outpatient,,,10.5,6.3,,1.89,18,,,percent of total billed charges,pays at 18% of total charges,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.25,50,,,percent of total billed charges,pays at 50% of total billed charges,7.35,70,,,percent of total billed charges,70% of total billed charges,7.88,75,,,percent of total billed charges,75% of total billed charges,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,10.5,
TRAY DUAL LUMEN PICC,3759803,CDM,278,RC,C1751,HCPCS,Outpatient,,,163,97.8,,29.34,18,,,percent of total billed charges,pays at 18% of total charges,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.1,70,,,percent of total billed charges,70% of total billed charges,122.25,75,,,percent of total billed charges,75% of total billed charges,81.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.54,163,
DRSG FOAM W ADHSV BORDER,3759804,CDM,272,RC,,,Outpatient,,,14.3,8.58,,2.57,18,,,percent of total billed charges,pays at 18% of total charges,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.15,50,,,percent of total billed charges,pays at 50% of total billed charges,10.01,70,,,percent of total billed charges,70% of total billed charges,10.73,75,,,percent of total billed charges,75% of total billed charges,7.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.24,14.3,
DSG AQUACEL,3759805,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
KIT PNEUMOTHORAX,3759806,CDM,272,RC,,,Outpatient,,,136,81.6,,24.48,18,,,percent of total billed charges,pays at 18% of total charges,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68,50,,,percent of total billed charges,pays at 50% of total billed charges,95.2,70,,,percent of total billed charges,70% of total billed charges,102,75,,,percent of total billed charges,75% of total billed charges,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,136,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,136,
DSG AQUACEL FOAM,3759807,CDM,272,RC,,,Outpatient,,,11,6.6,,1.98,18,,,percent of total billed charges,pays at 18% of total charges,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.5,50,,,percent of total billed charges,pays at 50% of total billed charges,7.7,70,,,percent of total billed charges,70% of total billed charges,8.25,75,,,percent of total billed charges,75% of total billed charges,5.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.72,11,
WEDGE 45 DEG,3759808,CDM,272,RC,,,Outpatient,,,17.5,10.5,,3.15,18,,,percent of total billed charges,pays at 18% of total charges,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.75,50,,,percent of total billed charges,pays at 50% of total billed charges,12.25,70,,,percent of total billed charges,70% of total billed charges,13.13,75,,,percent of total billed charges,75% of total billed charges,8.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.74,17.5,
PAD SENSA TAC WOUND VAC,3759809,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
CLOSURE SKIN STERI STRIP,3759810,CDM,272,RC,,,Outpatient,,,11.5,6.9,,2.07,18,,,percent of total billed charges,pays at 18% of total charges,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.75,50,,,percent of total billed charges,pays at 50% of total billed charges,8.05,70,,,percent of total billed charges,70% of total billed charges,8.63,75,,,percent of total billed charges,75% of total billed charges,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,11.5,
GAUZE W CALAMINE UNNA BOOT,3759811,CDM,272,RC,,,Outpatient,,,13.5,8.1,,2.43,18,,,percent of total billed charges,pays at 18% of total charges,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.75,50,,,percent of total billed charges,pays at 50% of total billed charges,9.45,70,,,percent of total billed charges,70% of total billed charges,10.13,75,,,percent of total billed charges,75% of total billed charges,6.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,13.5,
MEPITEL,3759813,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
STRIP PACKING PLAIN,3759814,CDM,272,RC,,,Outpatient,,,17,10.2,,3.06,18,,,percent of total billed charges,pays at 18% of total charges,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.5,50,,,percent of total billed charges,pays at 50% of total billed charges,11.9,70,,,percent of total billed charges,70% of total billed charges,12.75,75,,,percent of total billed charges,75% of total billed charges,8.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.66,17,
GAUZE VASELINE,3759815,CDM,272,RC,,,Outpatient,,,6.5,3.9,,1.17,18,,,percent of total billed charges,pays at 18% of total charges,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,6.5,
LYOFOAM EXTRA 10 X 10CM,3759816,CDM,272,RC,,,Outpatient,,,11.96,7.18,,2.15,18,,,percent of total billed charges,pays at 18% of total charges,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.98,50,,,percent of total billed charges,pays at 50% of total billed charges,8.37,70,,,percent of total billed charges,70% of total billed charges,8.97,75,,,percent of total billed charges,75% of total billed charges,5.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.87,11.96,
DSG MEPILEX AG 4X4,3759818,CDM,272,RC,,,Outpatient,,,20,12,,3.6,18,,,percent of total billed charges,pays at 18% of total charges,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10,50,,,percent of total billed charges,pays at 50% of total billed charges,14,70,,,percent of total billed charges,70% of total billed charges,15,75,,,percent of total billed charges,75% of total billed charges,10,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.13,20,
INSERT TEMP STRAIGHT BLADDER CATH,3759819,CDM,761,RC,51701,HCPCS,Outpatient,,,126.89,76.13,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,95.17,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,97.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,57.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,48.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,60.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,114.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.88,373.66,
Ultrasound of bladder to measure urine capacity,3759820,CDM,761,RC,51798,HCPCS,Outpatient,,,189.9,113.94,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,142.43,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,151.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,145.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,85.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,72.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,91.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,170.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,184.98,
PAD QUICK PACING,3759821,CDM,272,RC,,,Outpatient,,,199.5,119.7,,35.91,18,,,percent of total billed charges,pays at 18% of total charges,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,99.75,50,,,percent of total billed charges,pays at 50% of total billed charges,139.65,70,,,percent of total billed charges,70% of total billed charges,149.63,75,,,percent of total billed charges,75% of total billed charges,99.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,159.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,139.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,199.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,179.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.26,199.5,
TRACH CARE NEO/PEDI,3759822,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
CATH MAC NEO/PEDI,3759823,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
TUBE CHEST FURMAN,3759824,CDM,272,RC,,,Outpatient,,,144,86.4,,25.92,18,,,percent of total billed charges,pays at 18% of total charges,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,50,,,percent of total billed charges,pays at 50% of total billed charges,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,144,
PHOTOTHERAPY GUARD,3759825,CDM,272,RC,,,Outpatient,,,14.5,8.7,,2.61,18,,,percent of total billed charges,pays at 18% of total charges,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.25,50,,,percent of total billed charges,pays at 50% of total billed charges,10.15,70,,,percent of total billed charges,70% of total billed charges,10.88,75,,,percent of total billed charges,75% of total billed charges,7.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,14.5,
INTRODUCER NEO/PEDI,3759826,CDM,272,RC,C1894,HCPCS,Outpatient,,,74.5,44.7,,13.41,18,,,percent of total billed charges,pays at 18% of total charges,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.15,70,,,percent of total billed charges,70% of total billed charges,55.88,75,,,percent of total billed charges,75% of total billed charges,37.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,59.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.67,74.5,
ABBOCATH,3759827,CDM,272,RC,,,Outpatient,,,32.5,19.5,,5.85,18,,,percent of total billed charges,pays at 18% of total charges,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.25,50,,,percent of total billed charges,pays at 50% of total billed charges,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,16.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,32.5,
SYS CHEST DRAIN NEO/PEDI,3759828,CDM,272,RC,,,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.5,50,,,percent of total billed charges,pays at 50% of total billed charges,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
PAD AED DEFIB,3759829,CDM,272,RC,,,Outpatient,,,87.75,52.65,,15.8,18,,,percent of total billed charges,pays at 18% of total charges,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.88,50,,,percent of total billed charges,pays at 50% of total billed charges,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,43.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,87.75,
CATH UMBILICAL,3759830,CDM,272,RC,,,Outpatient,,,122,73.2,,21.96,18,,,percent of total billed charges,pays at 18% of total charges,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61,50,,,percent of total billed charges,pays at 50% of total billed charges,85.4,70,,,percent of total billed charges,70% of total billed charges,91.5,75,,,percent of total billed charges,75% of total billed charges,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,122,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.12,122,
POSITIONER NEO/PEDI,3759831,CDM,272,RC,,,Outpatient,,,18.5,11.1,,3.33,18,,,percent of total billed charges,pays at 18% of total charges,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.25,50,,,percent of total billed charges,pays at 50% of total billed charges,12.95,70,,,percent of total billed charges,70% of total billed charges,13.88,75,,,percent of total billed charges,75% of total billed charges,9.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.9,18.5,
CATH REPLOGLE,3759832,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
POSITIONER HEAD GEL DISP,3759833,CDM,272,RC,,,Outpatient,,,25.5,15.3,,4.59,18,,,percent of total billed charges,pays at 18% of total charges,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.75,50,,,percent of total billed charges,pays at 50% of total billed charges,17.85,70,,,percent of total billed charges,70% of total billed charges,19.13,75,,,percent of total billed charges,75% of total billed charges,12.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,25.5,
SWADDLER NEONATE DISP,3759834,CDM,272,RC,,,Outpatient,,,22,13.2,,3.96,18,,,percent of total billed charges,pays at 18% of total charges,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11,50,,,percent of total billed charges,pays at 50% of total billed charges,15.4,70,,,percent of total billed charges,70% of total billed charges,16.5,75,,,percent of total billed charges,75% of total billed charges,11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.45,22,
KIT DBL LUMEN CVC PEDI,3759835,CDM,272,RC,C1751,HCPCS,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
KIT MULTI LUMEN CVC PEDI,3759836,CDM,272,RC,C1751,HCPCS,Outpatient,,,87.5,52.5,,15.75,18,,,percent of total billed charges,pays at 18% of total charges,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.25,70,,,percent of total billed charges,70% of total billed charges,65.63,75,,,percent of total billed charges,75% of total billed charges,43.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,87.5,
DEVICE VASCLR SECUREMENT PEDI,3759837,CDM,272,RC,,,Outpatient,,,13,7.8,,2.34,18,,,percent of total billed charges,pays at 18% of total charges,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.5,50,,,percent of total billed charges,pays at 50% of total billed charges,9.1,70,,,percent of total billed charges,70% of total billed charges,9.75,75,,,percent of total billed charges,75% of total billed charges,6.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.04,13,
CATH SUCTION 24 HR,3759838,CDM,272,RC,,,Outpatient,,,81,48.6,,14.58,18,,,percent of total billed charges,pays at 18% of total charges,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,81,
ADAPTER BIFUSE 2 TO 1,3759839,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
HY-TAPE ZINC PINK,3759840,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
TRANSWARMER,3759841,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
DRSG FOAM BACTERIOSTATIC,3759842,CDM,272,RC,,,Outpatient,,,15.75,9.45,,2.84,18,,,percent of total billed charges,pays at 18% of total charges,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.88,50,,,percent of total billed charges,pays at 50% of total billed charges,11.03,70,,,percent of total billed charges,70% of total billed charges,11.81,75,,,percent of total billed charges,75% of total billed charges,7.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,15.75,
SET URINARY DRAIN NEO PEDI,3759843,CDM,272,RC,,,Outpatient,,,108,64.8,,19.44,18,,,percent of total billed charges,pays at 18% of total charges,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54,50,,,percent of total billed charges,pays at 50% of total billed charges,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,108,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,108,
PUMP EPIDURAL DISP,3759844,CDM,272,RC,,,Outpatient,,,127.5,76.5,,22.95,18,,,percent of total billed charges,pays at 18% of total charges,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.75,50,,,percent of total billed charges,pays at 50% of total billed charges,89.25,70,,,percent of total billed charges,70% of total billed charges,95.63,75,,,percent of total billed charges,75% of total billed charges,63.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,102,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,127.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,114.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,127.5,
SLING PATIENT TRANSFER DISP,3759845,CDM,272,RC,,,Outpatient,,,54,32.4,,9.72,18,,,percent of total billed charges,pays at 18% of total charges,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27,50,,,percent of total billed charges,pays at 50% of total billed charges,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.46,54,
MILWAUKEE SPINAL ORTHOSIS,3759846,CDM,274,RC,L0830,HCPCS,Outpatient,,,1945,1167,,14051.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3969.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3969.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,972.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1361.5,70,,,percent of total billed charges,70% of total billed charges,1458.75,75,,,percent of total billed charges,75% of total billed charges,7144.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13892.41,350,,,Fee Schedule,350% of CMS OPPS Rate,4048.65,102,,,Fee Schedule,102% of CMS OPPS Rate,1945,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,875.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1361.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1167,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3969.26,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,739.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1361.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3969.26,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1945,230,,,Fee Schedule,230% of CMS OPPS Rate,933.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3969.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1945,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,304.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,3969.26,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,304.78,14051.18,
ELBOW ORTHOSIS W CUFFS,3759848,CDM,274,RC,L3730,HCPCS,Outpatient,,,1244.8,746.88,,4122.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1164.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1164.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,622.4,50,,,percent of total billed charges,pays at 50% of total billed charges,871.36,70,,,percent of total billed charges,70% of total billed charges,933.6,75,,,percent of total billed charges,75% of total billed charges,2096.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,995.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4075.61,350,,,Fee Schedule,350% of CMS OPPS Rate,1187.75,102,,,Fee Schedule,102% of CMS OPPS Rate,1244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,214.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,560.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,871.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,746.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1164.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,473.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,871.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1164.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1244.8,230,,,Fee Schedule,230% of CMS OPPS Rate,597.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1164.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1164.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,195.06,4122.19,
HELMET HARD PROTECT PREFAB,3759849,CDM,274,RC,A8001,HCPCS,Outpatient,,,193.5,116.1,,,,,,Other,Not Separately reimbursable,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.75,50,,,percent of total billed charges,pays at 50% of total billed charges,135.45,70,,,percent of total billed charges,70% of total billed charges,145.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,154.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,135.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.32,193.5,
ARM FRACTURE ORTHOTIC,3759850,CDM,274,RC,L3760,HCPCS,Outpatient,,,561,336.6,,1857.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,524.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280.5,50,,,percent of total billed charges,pays at 50% of total billed charges,392.7,70,,,percent of total billed charges,70% of total billed charges,420.75,75,,,percent of total billed charges,75% of total billed charges,944.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1836.52,350,,,Fee Schedule,350% of CMS OPPS Rate,535.21,102,,,Fee Schedule,102% of CMS OPPS Rate,561,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,96.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,252.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,392.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,336.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,524.72,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,213.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,392.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,524.72,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,561,230,,,Fee Schedule,230% of CMS OPPS Rate,269.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,524.72,100,,,Fee Schedule,100% of CMS OPPS Rate,561,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,524.72,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,87.91,1857.51,
PAD REPLACEMENT MIAMI J,3759851,CDM,274,RC,L0999,HCPCS,Outpatient,,,76.5,45.9,,13.77,18,,,percent of total billed charges,pays at 18% of total charges,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,50,,,percent of total billed charges,pays at 50% of total billed charges,53.55,70,,,percent of total billed charges,70% of total billed charges,57.38,75,,,percent of total billed charges,75% of total billed charges,38.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.99,76.5,
ORTHOTIC NON-CORROSIVE BAR EA,3759852,CDM,274,RC,L2780,HCPCS,Outpatient,,,80.5,48.3,,256.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.25,50,,,percent of total billed charges,pays at 50% of total billed charges,56.35,70,,,percent of total billed charges,70% of total billed charges,60.38,75,,,percent of total billed charges,75% of total billed charges,130.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254,350,,,Fee Schedule,350% of CMS OPPS Rate,74.02,102,,,Fee Schedule,102% of CMS OPPS Rate,80.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,36.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.57,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,30.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.57,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,80.5,230,,,Fee Schedule,230% of CMS OPPS Rate,38.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72.57,100,,,Fee Schedule,100% of CMS OPPS Rate,80.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.57,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,12.61,256.9,
SOFT INTERFAC BELOW KNEE,3759853,CDM,274,RC,L2820,HCPCS,Outpatient,,,88,52.8,,329.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,93.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44,50,,,percent of total billed charges,pays at 50% of total billed charges,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,167.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,325.92,350,,,Fee Schedule,350% of CMS OPPS Rate,94.98,102,,,Fee Schedule,102% of CMS OPPS Rate,88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,93.12,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.12,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,88,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93.12,100,,,Fee Schedule,100% of CMS OPPS Rate,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.12,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,13.79,329.64,
SOFT INTRFAC ABOVE KNEE,3759854,CDM,274,RC,L2830,HCPCS,Outpatient,,,95.5,57.3,,356.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,100.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.75,50,,,percent of total billed charges,pays at 50% of total billed charges,66.85,70,,,percent of total billed charges,70% of total billed charges,71.63,75,,,percent of total billed charges,75% of total billed charges,181.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,352.59,350,,,Fee Schedule,350% of CMS OPPS Rate,102.75,102,,,Fee Schedule,102% of CMS OPPS Rate,95.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,42.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,100.74,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,36.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,66.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.74,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,95.5,230,,,Fee Schedule,230% of CMS OPPS Rate,45.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100.74,100,,,Fee Schedule,100% of CMS OPPS Rate,95.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,100.74,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,14.96,356.62,
ANKLE DORSIFLEX ASST DEVICE,3759855,CDM,274,RC,L2210,HCPCS,Outpatient,,,80,48,,255.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,129.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.28,350,,,Fee Schedule,350% of CMS OPPS Rate,73.52,102,,,Fee Schedule,102% of CMS OPPS Rate,80,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.08,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.08,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,80,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72.08,100,,,Fee Schedule,100% of CMS OPPS Rate,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,72.08,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,12.54,255.16,
ANKLE JOINT DEVICE,3759856,CDM,274,RC,L2220,HCPCS,Outpatient,,,89,53.4,,331.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,93.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.5,50,,,percent of total billed charges,pays at 50% of total billed charges,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,168.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,327.88,350,,,Fee Schedule,350% of CMS OPPS Rate,95.55,102,,,Fee Schedule,102% of CMS OPPS Rate,89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,93.68,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,33.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.68,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,89,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93.68,100,,,Fee Schedule,100% of CMS OPPS Rate,89,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,93.68,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,13.95,331.63,
ANKLE JOINT LMTD MOTION EA,3759857,CDM,274,RC,L2200,HCPCS,Outpatient,,,83.84,50.3,,240.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.92,50,,,percent of total billed charges,pays at 50% of total billed charges,58.69,70,,,percent of total billed charges,70% of total billed charges,62.88,75,,,percent of total billed charges,75% of total billed charges,122.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,67.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.9,350,,,Fee Schedule,350% of CMS OPPS Rate,69.33,102,,,Fee Schedule,102% of CMS OPPS Rate,83.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,37.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.97,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,31.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,58.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.97,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,83.84,230,,,Fee Schedule,230% of CMS OPPS Rate,40.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67.97,100,,,Fee Schedule,100% of CMS OPPS Rate,83.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.97,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,13.14,240.61,
LACER FOR CUST ORTHOTIC,3759858,CDM,274,RC,L2320,HCPCS,Outpatient,,,228,136.8,,852.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,240.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,240.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114,50,,,percent of total billed charges,pays at 50% of total billed charges,159.6,70,,,percent of total billed charges,70% of total billed charges,171,75,,,percent of total billed charges,75% of total billed charges,433.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,842.56,350,,,Fee Schedule,350% of CMS OPPS Rate,245.54,102,,,Fee Schedule,102% of CMS OPPS Rate,228,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,240.73,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240.73,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,228,230,,,Fee Schedule,230% of CMS OPPS Rate,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240.73,100,,,Fee Schedule,100% of CMS OPPS Rate,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,240.73,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,35.73,852.18,
LOOP POSITIONING SLING,3759859,CDM,272,RC,,,Outpatient,,,110,66,,19.8,18,,,percent of total billed charges,pays at 18% of total charges,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55,50,,,percent of total billed charges,pays at 50% of total billed charges,77,70,,,percent of total billed charges,70% of total billed charges,82.5,75,,,percent of total billed charges,75% of total billed charges,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,110,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.24,110,
ASSIST MAXIAIR TRANSFER,3759860,CDM,272,RC,,,Outpatient,,,114,68.4,,20.52,18,,,percent of total billed charges,pays at 18% of total charges,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,50,,,percent of total billed charges,pays at 50% of total billed charges,79.8,70,,,percent of total billed charges,70% of total billed charges,85.5,75,,,percent of total billed charges,75% of total billed charges,57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,79.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,102.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,114,
MOUTHPIECE CALORIMETER,3759861,CDM,272,RC,,,Outpatient,,,30,18,,5.4,18,,,percent of total billed charges,pays at 18% of total charges,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15,50,,,percent of total billed charges,pays at 50% of total billed charges,21,70,,,percent of total billed charges,70% of total billed charges,22.5,75,,,percent of total billed charges,75% of total billed charges,15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.7,30,
PRODUCTIVITY INSRTN MIDLINE VENOUS CATH,3759862,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
DERMABOND ADHESIVE PRINCEO,3759863,CDM,272,RC,,,Outpatient,,,229.5,137.7,,41.31,18,,,percent of total billed charges,pays at 18% of total charges,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,50,,,percent of total billed charges,pays at 50% of total billed charges,160.65,70,,,percent of total billed charges,70% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,114.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.96,229.5,
ISCHIAL CONTAINMENT SOCKET ADD TO LE,3759864,CDM,274,RC,L2525,HCPCS,Outpatient,,,1397.3,838.38,,4627.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1307.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1307.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,698.65,50,,,percent of total billed charges,pays at 50% of total billed charges,978.11,70,,,percent of total billed charges,70% of total billed charges,1047.98,75,,,percent of total billed charges,75% of total billed charges,2352.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1117.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4574.96,350,,,Fee Schedule,350% of CMS OPPS Rate,1333.27,102,,,Fee Schedule,102% of CMS OPPS Rate,1397.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,240.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,628.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,978.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,838.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1307.13,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,530.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,978.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1307.13,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1397.3,230,,,Fee Schedule,230% of CMS OPPS Rate,670.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1307.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1307.13,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,218.96,4627.24,
KIT MIDLINE CHANGE,3759865,CDM,272,RC,,,Outpatient,,,25.4,15.24,,4.57,18,,,percent of total billed charges,pays at 18% of total charges,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.7,50,,,percent of total billed charges,pays at 50% of total billed charges,17.78,70,,,percent of total billed charges,70% of total billed charges,19.05,75,,,percent of total billed charges,75% of total billed charges,12.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.98,25.4,
PRODUCTIVITY INSRTN PICC,3759866,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
TRAY MIDLINE CATH,3759867,CDM,272,RC,C1751,HCPCS,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
PROSTHETIC SOCKET ORTHOSES ADD TO LE,3759868,CDM,274,RC,L2350,HCPCS,Outpatient,,,1088.39,653.03,,3604.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1018.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,544.2,50,,,percent of total billed charges,pays at 50% of total billed charges,761.87,70,,,percent of total billed charges,70% of total billed charges,816.29,75,,,percent of total billed charges,75% of total billed charges,1832.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,870.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3563.53,350,,,Fee Schedule,350% of CMS OPPS Rate,1038.51,102,,,Fee Schedule,102% of CMS OPPS Rate,1088.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,489.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,761.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,653.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1018.15,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,413.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,761.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1018.15,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1088.39,230,,,Fee Schedule,230% of CMS OPPS Rate,522.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1018.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1018.15,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,170.55,3604.25,
WHFO FLEXOR HINGE CUSTOM,3759970,CDM,274,RC,L3900,HCPCS,Outpatient,,,1488.19,892.91,,4855.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1371.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,744.1,50,,,percent of total billed charges,pays at 50% of total billed charges,1041.73,70,,,percent of total billed charges,70% of total billed charges,1116.14,75,,,percent of total billed charges,75% of total billed charges,2468.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1190.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4800.57,350,,,Fee Schedule,350% of CMS OPPS Rate,1399.02,102,,,Fee Schedule,102% of CMS OPPS Rate,1488.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,256.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,669.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1041.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,892.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1371.59,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,565.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1041.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1371.59,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1488.19,230,,,Fee Schedule,230% of CMS OPPS Rate,714.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1371.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1488.19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,233.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1371.59,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,233.2,4855.43,
WHFO NONTORSION JOINT(S),3759972,CDM,274,RC,L3931,HCPCS,Outpatient,,,184.33,110.6,,763.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,215.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,92.17,50,,,percent of total billed charges,pays at 50% of total billed charges,129.03,70,,,percent of total billed charges,70% of total billed charges,138.25,75,,,percent of total billed charges,75% of total billed charges,387.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,754.39,350,,,Fee Schedule,350% of CMS OPPS Rate,219.85,102,,,Fee Schedule,102% of CMS OPPS Rate,184.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,82.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,215.54,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,70.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,129.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,215.54,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,184.33,230,,,Fee Schedule,230% of CMS OPPS Rate,88.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,215.54,100,,,Fee Schedule,100% of CMS OPPS Rate,184.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,215.54,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.88,763.01,
CO2 MONITORING NASAL CANNULA,3759974,CDM,272,RC,,,Outpatient,,,29.64,17.78,,5.34,18,,,percent of total billed charges,pays at 18% of total charges,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,50,,,percent of total billed charges,pays at 50% of total billed charges,20.75,70,,,percent of total billed charges,70% of total billed charges,22.23,75,,,percent of total billed charges,75% of total billed charges,14.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,29.64,
CATH NASAL RHINO,3759975,CDM,272,RC,,,Outpatient,,,80,48,,14.4,18,,,percent of total billed charges,pays at 18% of total charges,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
KIT ACUTE CARE SUCTION,3759976,CDM,272,RC,,,Outpatient,,,33.5,20.1,,6.03,18,,,percent of total billed charges,pays at 18% of total charges,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.75,50,,,percent of total billed charges,pays at 50% of total billed charges,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,16.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,33.5,
SYSTEM FECAL MGMT,3759977,CDM,272,RC,,,Outpatient,,,397.5,238.5,,71.55,18,,,percent of total billed charges,pays at 18% of total charges,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,198.75,50,,,percent of total billed charges,pays at 50% of total billed charges,278.25,70,,,percent of total billed charges,70% of total billed charges,298.13,75,,,percent of total billed charges,75% of total billed charges,198.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,318,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,304.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,397.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,357.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.29,397.5,
HAND FINGER ORTHOSIS WO JOINT,3759978,CDM,274,RC,L3923,HCPCS,Outpatient,,,126,75.6,,323.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63,50,,,percent of total billed charges,pays at 50% of total billed charges,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,164.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.45,350,,,Fee Schedule,350% of CMS OPPS Rate,93.1,102,,,Fee Schedule,102% of CMS OPPS Rate,126,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,126,230,,,Fee Schedule,230% of CMS OPPS Rate,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,100% of CMS OPPS Rate,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,19.74,323.1,
CAST SUPPLIES,3759979,CDM,270,RC,,,Outpatient,,,182.5,109.5,,32.85,18,,,percent of total billed charges,pays at 18% of total charges,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.25,50,,,percent of total billed charges,pays at 50% of total billed charges,127.75,70,,,percent of total billed charges,70% of total billed charges,136.88,75,,,percent of total billed charges,75% of total billed charges,91.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,182.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,164.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.6,182.5,
WRIST SPLINT,3759980,CDM,274,RC,L3908,HCPCS,Outpatient,,,119.5,71.7,,222.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,59.75,50,,,percent of total billed charges,pays at 50% of total billed charges,83.65,70,,,percent of total billed charges,70% of total billed charges,89.63,75,,,percent of total billed charges,75% of total billed charges,113.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.05,350,,,Fee Schedule,350% of CMS OPPS Rate,64.13,102,,,Fee Schedule,102% of CMS OPPS Rate,119.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,53.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,45.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,83.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,119.5,230,,,Fee Schedule,230% of CMS OPPS Rate,57.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,100% of CMS OPPS Rate,119.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,18.73,222.56,
IMMOB SHOULDER ALL,3759981,CDM,274,RC,L3670,HCPCS,Outpatient,,,81,48.6,,436.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,221.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,431.2,350,,,Fee Schedule,350% of CMS OPPS Rate,125.66,102,,,Fee Schedule,102% of CMS OPPS Rate,81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,123.2,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.2,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,81,230,,,Fee Schedule,230% of CMS OPPS Rate,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123.2,100,,,Fee Schedule,100% of CMS OPPS Rate,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,123.2,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,12.69,436.13,
TRAY CATH W/FOLEY,3759982,CDM,272,RC,,,Outpatient,,,133.5,80.1,,24.03,18,,,percent of total billed charges,pays at 18% of total charges,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.75,50,,,percent of total billed charges,pays at 50% of total billed charges,93.45,70,,,percent of total billed charges,70% of total billed charges,100.13,75,,,percent of total billed charges,75% of total billed charges,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,133.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,133.5,
TUBE SHILEY ALL,3759983,CDM,272,RC,,,Outpatient,,,241.5,144.9,,43.47,18,,,percent of total billed charges,pays at 18% of total charges,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.75,50,,,percent of total billed charges,pays at 50% of total billed charges,169.05,70,,,percent of total billed charges,70% of total billed charges,181.13,75,,,percent of total billed charges,75% of total billed charges,120.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,169.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,241.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,217.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.84,241.5,
IMMOBILIZER KNEE ALL,3759985,CDM,270,RC,L1830,HCPCS,Outpatient,,,338,202.8,,276.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,169,50,,,percent of total billed charges,pays at 50% of total billed charges,236.6,70,,,percent of total billed charges,70% of total billed charges,253.5,75,,,percent of total billed charges,75% of total billed charges,140.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.74,350,,,Fee Schedule,350% of CMS OPPS Rate,79.77,102,,,Fee Schedule,102% of CMS OPPS Rate,258.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,152.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,236.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,128.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,236.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,179.88,230,,,Fee Schedule,230% of CMS OPPS Rate,162.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,78.21,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,52.96,304.2,
CONVOLUTED BUCKS BOOTS AL,3759987,CDM,272,RC,,,Outpatient,,,175.5,105.3,,31.59,18,,,percent of total billed charges,pays at 18% of total charges,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.75,50,,,percent of total billed charges,pays at 50% of total billed charges,122.85,70,,,percent of total billed charges,70% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,87.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,175.5,
TUBE GASTRO ALL,3759988,CDM,272,RC,,,Outpatient,,,274,164.4,,49.32,18,,,percent of total billed charges,pays at 18% of total charges,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,50,,,percent of total billed charges,pays at 50% of total billed charges,191.8,70,,,percent of total billed charges,70% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,137,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,274,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,274,
CANNULA INNER SHILEY ALL,3759989,CDM,272,RC,,,Outpatient,,,175.5,105.3,,31.59,18,,,percent of total billed charges,pays at 18% of total charges,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.75,50,,,percent of total billed charges,pays at 50% of total billed charges,122.85,70,,,percent of total billed charges,70% of total billed charges,131.63,75,,,percent of total billed charges,75% of total billed charges,87.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.5,175.5,
DRSG ULTRA ABSORBENT,3759990,CDM,272,RC,,,Outpatient,,,10.9,6.54,,1.96,18,,,percent of total billed charges,pays at 18% of total charges,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.45,50,,,percent of total billed charges,pays at 50% of total billed charges,7.63,70,,,percent of total billed charges,70% of total billed charges,8.18,75,,,percent of total billed charges,75% of total billed charges,5.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.71,10.9,
DRSG COLLAGEN ORC AG,3759991,CDM,272,RC,,,Outpatient,,,22.15,13.29,,3.99,18,,,percent of total billed charges,pays at 18% of total charges,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.08,50,,,percent of total billed charges,pays at 50% of total billed charges,15.51,70,,,percent of total billed charges,70% of total billed charges,16.61,75,,,percent of total billed charges,75% of total billed charges,11.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.47,22.15,
IV START SUPPLIES,3759992,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
SLEEVE SCD,3759993,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
DRESSING SUPPLIES LG,3759994,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
DRESSING SUPPLIES MED,3759995,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
DRESSING SUPPLIES SM,3759996,CDM,272,RC,,,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.25,50,,,percent of total billed charges,pays at 50% of total billed charges,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
KIT PORT ACCESS,3759997,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
TLSO FLEX RGD PANEL OTS,3759999,CDM,272,RC,,,Outpatient,,,776.35,465.81,,139.74,18,,,percent of total billed charges,pays at 18% of total charges,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,388.18,50,,,percent of total billed charges,pays at 50% of total billed charges,543.45,70,,,percent of total billed charges,70% of total billed charges,582.26,75,,,percent of total billed charges,75% of total billed charges,388.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,621.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,465.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,593.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,543.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,465.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,543.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,776.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,698.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.65,776.35,
TRANSFUSION BLOOD OR BLD COMPONENTS,3760001,CDM,391,RC,36430,HCPCS,Outpatient,,,1050,630,,1312.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,370.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,764.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,735,70,,,percent of total billed charges,70% of total billed charges,787.5,75,,,percent of total billed charges,75% of total billed charges,667.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,840,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1297.39,350,,,Fee Schedule,350% of CMS OPPS Rate,378.09,103,,,Fee Schedule,103% of CMS OPPS Rate,803.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,180.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,735,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,630,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,735,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,852.57,100,,,Fee Schedule,100% of CMS OPPS Rate,504,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,945,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,164.54,1373,
ISOLATION,3760002,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
SODIUM CHLORIDE 100ML ADV,3770001,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 25000-1/2NS 500,3770008,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 10% 500ML,3770024,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 10% 250ML,3770025,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 10% 1000ML,3770026,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 150ML,3770032,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% IN WATER 25 ML,3770033,CDM,636,RC,J7060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% NO DEHP/PVC 50 ML,3770035,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 500ML VISIV,3770039,CDM,636,RC,J7060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 500ML,3770040,CDM,636,RC,J7060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 1000ML,3770042,CDM,636,RC,J7070,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5W PARTIAL FILL 50ML,3770044,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5W PARTIAL FILL 50ML FOIL,3770045,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5W 5%/PARTIAL FILL 100ML,3770046,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5W PARTIAL FILL 100ML FOIL,3770047,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5W 20MEQ KCL 1000ML,3770048,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 1000ML (NO DEHP/PVC),3770049,CDM,636,RC,J7070,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOPAMINE 3200MCG/ML 250ML,3770055,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5%/LR 1000ML,3770056,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5NS 500ML,3770058,CDM,636,RC,J7042,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5NS 1000ML,3770060,CDM,636,RC,J7042,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 250ML NO DEHP/PVC,3770061,CDM,636,RC,J7050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 500ML NO DEHP/PVC,3770062,CDM,636,RC,J7040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 1000 ML NO DEHP/PVC,3770063,CDM,636,RC,J7030,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5%-1/2NS 500ML,3770064,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5%-1/2NS 1000ML,3770066,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D51/2NS 20MEQ KCL 1000ML,3770068,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D51/2NS 40MEQ KCL 1000ML,3770072,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D51/4NS (LIFECARE) 500ML,3770074,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D51/4NS(LIFECARE) 1000ML,3770076,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D50W 500ML IN 1000ML,3770084,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D70W 500ML IN 1000ML,3770088,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOPAMINE 400MG/D5W 250ML,3770090,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOPAMINE 400MG/D5W 250ML,3770090,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 70% 2000 ML,3770091,CDM,636,RC,J7799,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYCINE 1.5% IRRIG 3000ML,3770106,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTATED RINGERS 1000ML,3770112,CDM,636,RC,J7120,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTATED RINGERS 250ML NO  DEHP/PVC,3770113,CDM,636,RC,J7120,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACT RINGERS IRRIG 3000 ML,3770114,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 0.4%/D5W 500ML,3770116,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAT EMULSION 20% 500ML,3770122,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAT EMULSION 20% 250ML,3770123,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAT EMULSION 20% 100ML,3770124,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MANNITOL 20% 500ML,3770128,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MANNITOL 20% 250ML INJECTION,3770129,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ELECTROLYTE-A SOLN 500ML,3770136,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ELECTROLYTE-A SOLN 1000ML,3770137,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 0.9% IRRIG 3000ML,3770144,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.45% 500,3770145,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.45%1000ML,3770146,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD CL 0.45% 1000ML W KCL20,3770147,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.225% 1000ML,3770148,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETIC ACID 0.25% IRRIGATION 1000ML,3770149,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 0.9% IRRIG 2000ML,3770151,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 250ML,3770152,CDM,636,RC,J7050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 500ML,3770156,CDM,636,RC,J7040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 1000ML,3770158,CDM,636,RC,J7030,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% IRRIG 250ML PB,3770162,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% IRRIG 500ML PB,3770164,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% IRRIG 1000ML PB,3770166,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% PARTIAL FILL 50ML FOIL,3770167,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% PARTIAL FILL50ML,3770168,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% PARTIAL FILL 100ML,3770169,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NACL 0.9% PARTIAL FILL 100ML (FOIL),3770170,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 3 500ML,3770171,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
0.9% SODIUM CHLIRIDE 100ML FD,3770173,CDM,636,RC,J7050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ST WATER FOR INJ 1000ML,3770174,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
0.9% SODIUM CHLIRIDE 250ML FD,3770175,CDM,636,RC,J7050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ST WATER IRRIG PB 250ML,3770176,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ST WATER IRRIG PB 500ML,3770178,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ST WATER IRRIG PB 1000ML,3770180,CDM,250,RC,,,Outpatient,,,301,180.6,,54.18,18,,,percent of total billed charges,pays at 18% of total charges,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.5,50,,,percent of total billed charges,pays at 50% of total billed charges,210.7,70,,,percent of total billed charges,70% of total billed charges,225.75,75,,,percent of total billed charges,75% of total billed charges,150.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,301,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.17,301,
ACETIC ACID 3% IRR PB 500ML,3770181,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ST WATER IRRIG (BAG) 3000,3770184,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUMIN HUMAN 25% 50ML VL,3770252,CDM,636,RC,P9047,HCPCS,Outpatient,,,0.01,0.01,,187.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,53.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,95.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.78,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,122.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,187.9,
ALBUMIN HUM  5% 250ML,3770256,CDM,636,RC,P9045,HCPCS,Outpatient,,,0.01,0.01,,187.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,53.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,95.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.78,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,122.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,53.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,187.9,
HETASTARCH 6% IN NS 500,3770260,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 1000U/NS 500ML,3770272,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NTG 50MG / D5W 250ML,3770273,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NTG 0.2MG / D5W ML 1ML,3770274,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMINO ACIDS 15%   100ML,3770502,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTATED RINGERS 500ML,3770665,CDM,636,RC,J7120,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 250 UNITS/D10 500,3770700,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 100UNIT 1/2NS 100,3770701,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 100UNIT NS 100ML,3770702,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D51/2NS 30MEQ KCL 1000ML,3771001,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 150ML,3771003,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5%/AA 4% 100ML,3771085,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMINO ACID 10% 100ML,3771235,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOBUTAMINE HCL W DEXTROSE,3771236,CDM,258,RC,J1250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULF 4GR/100ML,3771586,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULFATE 1GM/100M,3771587,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULFATE 2GM/50ML,3771588,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 20MEQ KCL 1000ML,3771670,CDM,250,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARDIOPLEGIA DEL NIDO 1000ML INJ,3771800,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 250ML,3771874,CDM,636,RC,J7060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.45% 250ML,3772151,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULF 500MG INJ(40GM/1000ML BAG,3772152,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"HEPARIN 25,000/D5W 500",3772369,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5% 250ML VISIV,3772874,CDM,636,RC,J7060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D51/2NS 10MEQ KCL 1000ML,3773255,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5NS 40MEQ KCL 1000ML,3773256,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5NS 20MEQ KCL 1000ML,3773258,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 0.45% 100ML,3773524,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULF 20GM/500ML,3773543,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESMOLOL 10MG/ML 250ML,3773547,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 40MEQ KCL 1000ML,3774097,CDM,250,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 10%/AA 4% 100ML,3774342,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 10%/AA 2.5% 250ML,3774343,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 5%/AA 2.5 250ML,3774344,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINIMIX 5/20 1000 ML,3775552,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINIMIX 5/15 1000 ML,3775554,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMINO ACID 10% 500ML,3775556,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREMASOL 10% 500 ML,3775557,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 100 ML MINIBAG SINGLE,3775962,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SORBITOL 3  3000ML,3775963,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
D5LR 20MEQ KCL 1000ML,3775964,CDM,250,RC,J7120,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NS 100ML MINIBAG,3775965,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 250ML ADV,3777101,CDM,636,RC,J7050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ELECTROLYTE R SOLN 1000ML,3777670,CDM,258,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RPR EXTREMETIES < 2.6-7.5 CM,3780002,CDM,450,RC,,,Outpatient,,,437.8,262.68,,78.8,18,,,percent of total billed charges,pays at 18% of total charges,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.9,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,328.35,75,,,percent of total billed charges,75% of total billed charges,218.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,437.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,394.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.6,437.8,
BURN PARTIAL THICKNESS SMALL,3780003,CDM,450,RC,,,Outpatient,,,186.2,111.72,,33.52,18,,,percent of total billed charges,pays at 18% of total charges,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.1,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,139.65,75,,,percent of total billed charges,75% of total billed charges,93.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,186.2,
BURN PARTIAL THICKNESS MED,3780004,CDM,450,RC,,,Outpatient,,,186.2,111.72,,33.52,18,,,percent of total billed charges,pays at 18% of total charges,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.1,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,139.65,75,,,percent of total billed charges,75% of total billed charges,93.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.18,186.2,
CLSD TX OF HUMERAL SHAFT FX,3780006,CDM,450,RC,,,Outpatient,,,232.68,139.61,,41.88,18,,,percent of total billed charges,pays at 18% of total charges,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.34,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,116.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,232.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.46,232.68,
DEBRIDE OPEN FX AND/OR DISLOCATION,3780007,CDM,450,RC,,,Outpatient,,,918.56,551.14,,165.34,18,,,percent of total billed charges,pays at 18% of total charges,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,459.28,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,688.92,75,,,percent of total billed charges,75% of total billed charges,459.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,734.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,551.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,702.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,642.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,551.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,918.56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,826.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.94,918.56,
RPR COMPLEX HANDS/FEET 1.1 CM TO 2.5XM,3780008,CDM,450,RC,,,Outpatient,,,717.12,430.27,,129.08,18,,,percent of total billed charges,pays at 18% of total charges,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.56,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,537.84,75,,,percent of total billed charges,75% of total billed charges,358.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,548.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,717.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,645.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.37,717.12,
RPR INTRMDT SCLP/AXIL/TRNK/EXT 7.6 -12.5,3780009,CDM,450,RC,,,Outpatient,,,437.8,262.68,,78.8,18,,,percent of total billed charges,pays at 18% of total charges,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.9,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,328.35,75,,,percent of total billed charges,75% of total billed charges,218.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,437.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,394.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.6,437.8,
SANE EXAM,3780010,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
CLSD TX FINGER DISLCTN W MANIP NO ANES,3780011,CDM,450,RC,,,Outpatient,,,232.68,139.61,,41.88,18,,,percent of total billed charges,pays at 18% of total charges,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.34,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,116.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,232.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.46,232.68,
CLSD TX FINGER FX DISLCTN W MANIP,3780012,CDM,450,RC,,,Outpatient,,,1008.8,605.28,,181.58,18,,,percent of total billed charges,pays at 18% of total charges,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,181.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,504.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,756.6,75,,,percent of total billed charges,75% of total billed charges,504.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,807.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,605.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,771.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,706.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,605.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1008.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,907.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.08,1008.8,
LARYNGOSCOPY FLEX,3780013,CDM,450,RC,,,Outpatient,,,260.8,156.48,,46.94,18,,,percent of total billed charges,pays at 18% of total charges,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,195.6,75,,,percent of total billed charges,75% of total billed charges,130.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,260.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,234.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.87,260.8,
LARYNGOSCOPY FLEX RMVL FB(S),3780014,CDM,450,RC,,,Outpatient,,,791.6,474.96,,142.49,18,,,percent of total billed charges,pays at 18% of total charges,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.8,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,593.7,75,,,percent of total billed charges,75% of total billed charges,395.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,633.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,474.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,605.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,554.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,474.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,791.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,712.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.04,791.6,
CLSD TX PRXML HUMERAL FX W MANIPLTN,3780017,CDM,450,RC,,,Outpatient,,,1454.32,872.59,,261.78,18,,,percent of total billed charges,pays at 18% of total charges,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,727.16,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1090.74,75,,,percent of total billed charges,75% of total billed charges,727.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1163.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,872.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1112.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1018.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,872.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1018.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,698.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1454.32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1308.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.89,1454.32,
THORACOTOMY WITH CARDIAC MASSAGE,3780018,CDM,450,RC,,,Outpatient,,,11253.01,6751.81,,2025.54,18,,,percent of total billed charges,pays at 18% of total charges,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2025.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5626.51,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,8439.76,75,,,percent of total billed charges,75% of total billed charges,5626.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9002.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6751.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8608.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5063.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7877.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6751.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7877.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5401.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11253.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10127.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1763.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.35,11253.01,
TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMB,3780019,CDM,450,RC,31605,HCPCS,Outpatient,,,2053.11,1231.87,,668.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,937.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1539.83,75,,,percent of total billed charges,75% of total billed charges,340.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1642.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.27,350,,,Fee Schedule,350% of CMS OPPS Rate,192.71,103,,,Fee Schedule,103% of CMS OPPS Rate,1570.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,353.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,923.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1437.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1231.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1437.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,434.54,100,,,Fee Schedule,100% of CMS OPPS Rate,985.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1847.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,321.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,1847.8,
RMVL DISLODGED TOOTH,3780020,CDM,450,RC,,,Outpatient,,,160.8,96.48,,28.94,18,,,percent of total billed charges,pays at 18% of total charges,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,120.6,75,,,percent of total billed charges,75% of total billed charges,80.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,160.8,
VIRTUAL ER OBSERVATION HR,3780022,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
ED PSYCH OBSERVATION HR,3780024,CDM,762,RC,G0378,HCPCS,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,2247,
RPR INTRMDT WND > 30CM,3780027,CDM,450,RC,,,Outpatient,,,887.33,532.4,,159.72,18,,,percent of total billed charges,pays at 18% of total charges,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.67,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,665.5,75,,,percent of total billed charges,75% of total billed charges,443.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,709.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,532.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,678.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,621.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,532.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,887.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,798.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.04,887.33,
INC & DRNG ABCESS CMPLX,3780028,CDM,450,RC,,,Outpatient,,,365.6,219.36,,65.81,18,,,percent of total billed charges,pays at 18% of total charges,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.8,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,274.2,75,,,percent of total billed charges,75% of total billed charges,182.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,365.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,329.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.29,365.6,
INCSN AND DRNG DENTAL STRCTRS,3780029,CDM,450,RC,,,Outpatient,,,160.8,96.48,,28.94,18,,,percent of total billed charges,pays at 18% of total charges,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,120.6,75,,,percent of total billed charges,75% of total billed charges,80.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,160.8,
INC & DRNG ABCESS SIMPLE,3780030,CDM,450,RC,,,Outpatient,,,297.44,178.46,,53.54,18,,,percent of total billed charges,pays at 18% of total charges,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,223.08,75,,,percent of total billed charges,75% of total billed charges,148.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,297.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.61,297.44,
RMVL FOREIGN BODY SIMPLE,3780031,CDM,450,RC,,,Outpatient,,,297.44,178.46,,53.54,18,,,percent of total billed charges,pays at 18% of total charges,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,223.08,75,,,percent of total billed charges,75% of total billed charges,148.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,297.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.61,297.44,
INC & DRNG HEMATOMA OR SEROMA FLUID,3780033,CDM,450,RC,,,Outpatient,,,735.05,441.03,,132.31,18,,,percent of total billed charges,pays at 18% of total charges,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.53,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,551.29,75,,,percent of total billed charges,75% of total billed charges,367.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,588.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,441.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,562.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,514.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,735.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,661.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.18,735.05,
PUNCT ASP ABSCS HEMATOM OR CYST,3780034,CDM,450,RC,,,Outpatient,,,402.16,241.3,,72.39,18,,,percent of total billed charges,pays at 18% of total charges,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.08,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,301.62,75,,,percent of total billed charges,75% of total billed charges,201.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,321.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,307.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.16,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,361.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,402.16,
DEBRIDE INFECTED SKIN,3780035,CDM,450,RC,,,Outpatient,,,241.5,144.9,,43.47,18,,,percent of total billed charges,pays at 18% of total charges,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,181.13,75,,,percent of total billed charges,75% of total billed charges,120.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,241.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,217.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.84,241.5,
DEBRIDMENT SKIN,3780036,CDM,450,RC,,,Outpatient,,,310,186,,55.8,18,,,percent of total billed charges,pays at 18% of total charges,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,310,
AVULSION NAIL PLATE PARTL OR COMPL,3780037,CDM,450,RC,,,Outpatient,,,578.35,347.01,,104.1,18,,,percent of total billed charges,pays at 18% of total charges,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,289.18,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,433.76,75,,,percent of total billed charges,75% of total billed charges,289.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,462.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,442.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,404.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,347.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,578.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,520.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.63,578.35,
EVAC SUBUNGUAL HEMATOMA,3780039,CDM,450,RC,,,Outpatient,,,87.2,52.32,,15.7,18,,,percent of total billed charges,pays at 18% of total charges,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.6,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,65.4,75,,,percent of total billed charges,75% of total billed charges,43.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.66,87.2,
RPR SUPERFICIALWND 0-2.5,3780040,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR SUPERFIC WND 2.6-7.5,3780041,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR SUPERFIC WND 7.6-12.5,3780042,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR SUPERFCC WND 12.6-20,3780043,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR SUPERFIC WND 20.1-30,3780044,CDM,450,RC,,,Outpatient,,,291.96,175.18,,52.55,18,,,percent of total billed charges,pays at 18% of total charges,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.98,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,218.97,75,,,percent of total billed charges,75% of total billed charges,145.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,204.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,291.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,262.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.75,291.96,
RPR SUPERFIC WND > 30CM,3780045,CDM,450,RC,,,Outpatient,,,324.4,194.64,,58.39,18,,,percent of total billed charges,pays at 18% of total charges,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162.2,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,243.3,75,,,percent of total billed charges,75% of total billed charges,162.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,259.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,194.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,227.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,324.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,291.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.83,324.4,
RPR INTRMDT WND 0-2.5C,3780046,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR INTRMDT WND 2.6-5 CM,3780047,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR INTRMDT WND 5.1-7.5,3780048,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR INTRMDT WND 7.6-12.5,3780049,CDM,450,RC,,,Outpatient,,,356.84,214.1,,64.23,18,,,percent of total billed charges,pays at 18% of total charges,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,178.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.92,356.84,
RPR INTRMDT WND 12.6-20,3780050,CDM,450,RC,,,Outpatient,,,365.1,219.06,,65.72,18,,,percent of total billed charges,pays at 18% of total charges,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.55,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,273.83,75,,,percent of total billed charges,75% of total billed charges,182.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,365.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,328.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.21,365.1,
RPR INTRMDT WND 20.1-30CM,3780051,CDM,450,RC,,,Outpatient,,,365.1,219.06,,65.72,18,,,percent of total billed charges,pays at 18% of total charges,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.55,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,273.83,75,,,percent of total billed charges,75% of total billed charges,182.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,279.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,365.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,328.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.21,365.1,
RPR WND CMPX TNK 2.6-7.5,3780054,CDM,450,RC,,,Outpatient,,,544.28,326.57,,97.97,18,,,percent of total billed charges,pays at 18% of total charges,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.14,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,408.21,75,,,percent of total billed charges,75% of total billed charges,272.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.29,544.28,
RPR WND CMPX TNK EA ADD 5,3780055,CDM,450,RC,,,Outpatient,,,544.28,326.57,,97.97,18,,,percent of total billed charges,pays at 18% of total charges,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.14,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,408.21,75,,,percent of total billed charges,75% of total billed charges,272.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.29,544.28,
RPR CMPX WND A 1.1-2.5CM,3780056,CDM,450,RC,,,Outpatient,,,494.8,296.88,,89.06,18,,,percent of total billed charges,pays at 18% of total charges,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,371.1,75,,,percent of total billed charges,75% of total billed charges,247.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,494.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,445.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.54,494.8,
RPR CMPX WND A 2.6-7.5CM,3780057,CDM,450,RC,,,Outpatient,,,544.28,326.57,,97.97,18,,,percent of total billed charges,pays at 18% of total charges,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.14,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,408.21,75,,,percent of total billed charges,75% of total billed charges,272.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.29,544.28,
RPR CMPX WND A EA ADD 5CM,3780058,CDM,450,RC,,,Outpatient,,,544.28,326.57,,97.97,18,,,percent of total billed charges,pays at 18% of total charges,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.14,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,408.21,75,,,percent of total billed charges,75% of total billed charges,272.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.29,544.28,
RPR CMPX WND B 2.6-7.5CM,3780060,CDM,450,RC,,,Outpatient,,,544.28,326.57,,97.97,18,,,percent of total billed charges,pays at 18% of total charges,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.14,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,408.21,75,,,percent of total billed charges,75% of total billed charges,272.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.29,544.28,
RPR CMPX WND B EA ADD 5CM,3780061,CDM,450,RC,,,Outpatient,,,494.8,296.88,,89.06,18,,,percent of total billed charges,pays at 18% of total charges,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,371.1,75,,,percent of total billed charges,75% of total billed charges,247.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,494.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,445.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.54,494.8,
RPR CMPX WND C 1.0CM OR <,3780062,CDM,450,RC,,,Outpatient,,,494.8,296.88,,89.06,18,,,percent of total billed charges,pays at 18% of total charges,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,371.1,75,,,percent of total billed charges,75% of total billed charges,247.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,494.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,445.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.54,494.8,
RPR CMPX WND C 1.1-2.5CM,3780063,CDM,450,RC,,,Outpatient,,,494.8,296.88,,89.06,18,,,percent of total billed charges,pays at 18% of total charges,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,371.1,75,,,percent of total billed charges,75% of total billed charges,247.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,395.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,296.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,494.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,445.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.54,494.8,
RPR CMPX WND C 2.6-7.5CM,3780064,CDM,450,RC,,,Outpatient,,,544.28,326.57,,97.97,18,,,percent of total billed charges,pays at 18% of total charges,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.14,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,408.21,75,,,percent of total billed charges,75% of total billed charges,272.14,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,435.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,416.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,544.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,489.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.29,544.28,
RPR CMPX WND C EA ADD 5CM,3780065,CDM,450,RC,,,Outpatient,,,473,283.8,,85.14,18,,,percent of total billed charges,pays at 18% of total charges,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,354.75,75,,,percent of total billed charges,75% of total billed charges,236.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,473,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.12,473,
INIT TX 1ST DEG BURNS LOC,3780066,CDM,450,RC,,,Outpatient,,,272.8,163.68,,49.1,18,,,percent of total billed charges,pays at 18% of total charges,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,204.6,75,,,percent of total billed charges,75% of total billed charges,136.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,218.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,208.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,272.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,245.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.75,272.8,
CLSD TX NOSE FX,3780069,CDM,450,RC,,,Outpatient,,,330.33,198.2,,59.46,18,,,percent of total billed charges,pays at 18% of total charges,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.17,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,247.75,75,,,percent of total billed charges,75% of total billed charges,165.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,264.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,198.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,330.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,297.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.76,330.33,
REPAIR BLOOD VESSEL LESION,3780072,CDM,450,RC,,,Outpatient,,,1266.73,760.04,,228.01,18,,,percent of total billed charges,pays at 18% of total charges,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633.37,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,950.05,75,,,percent of total billed charges,75% of total billed charges,633.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1013.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,760.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,969.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,886.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,760.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,886.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1266.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1140.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.5,1266.73,
INCSN AND DRNG PILONIDAL CYST,3780081,CDM,450,RC,,,Outpatient,,,1052.43,631.46,,189.44,18,,,percent of total billed charges,pays at 18% of total charges,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,526.22,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,789.32,75,,,percent of total billed charges,75% of total billed charges,526.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,841.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,631.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,805.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,736.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,631.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,736.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1052.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,947.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.92,1052.43,
CLSD TX RADIAL HEAD OR NECK FX W MANIP,3780085,CDM,450,RC,,,Outpatient,,,268.8,161.28,,48.38,18,,,percent of total billed charges,pays at 18% of total charges,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,134.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,268.8,
CLSD TX RADIAL SHAFT FX W MANIP,3780087,CDM,450,RC,,,Outpatient,,,605.43,363.26,,108.98,18,,,percent of total billed charges,pays at 18% of total charges,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,454.07,75,,,percent of total billed charges,75% of total billed charges,302.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.87,605.43,
CLSD TX RADIAL & ULNA FX W MANIP,3780094,CDM,450,RC,,,Outpatient,,,295.68,177.41,,53.22,18,,,percent of total billed charges,pays at 18% of total charges,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.84,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,221.76,75,,,percent of total billed charges,75% of total billed charges,147.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,295.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,295.68,
CLSD TX DSTL RAD FX OR EPHYSL WO MANIP,3780095,CDM,450,RC,,,Outpatient,,,310,186,,55.8,18,,,percent of total billed charges,pays at 18% of total charges,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,310,
CLSD TX DSTL RAD FX OR EPHYSL W MANIP,3780096,CDM,450,RC,,,Outpatient,,,605.43,363.26,,108.98,18,,,percent of total billed charges,pays at 18% of total charges,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,454.07,75,,,percent of total billed charges,75% of total billed charges,302.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.87,605.43,
NASAL HEMORRHAGE CNTRL ANTERIOR,3780098,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
NASAL HEMORRHAGE CNTRL POSTERIOR,3780099,CDM,450,RC,,,Outpatient,,,135.94,81.56,,24.47,18,,,percent of total billed charges,pays at 18% of total charges,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.97,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,101.96,75,,,percent of total billed charges,75% of total billed charges,67.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.94,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.3,135.94,
CLSD TX ULNAR STYLOID FX,3780108,CDM,450,RC,,,Outpatient,,,268.8,161.28,,48.38,18,,,percent of total billed charges,pays at 18% of total charges,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,134.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,268.8,
LUNATE DX W MAN,3780110,CDM,450,RC,,,Outpatient,,,1113.82,668.29,,200.49,18,,,percent of total billed charges,pays at 18% of total charges,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,556.91,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,835.37,75,,,percent of total billed charges,75% of total billed charges,556.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1113.82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1002.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.54,1113.82,
CLSD TX WRIST BONE DISLOCATION,3780111,CDM,450,RC,,,Outpatient,,,268.8,161.28,,48.38,18,,,percent of total billed charges,pays at 18% of total charges,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,134.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,268.8,
CLSD TX DSTL RADIOULNAR DSLCTN W MANIP,3780112,CDM,450,RC,,,Outpatient,,,268.8,161.28,,48.38,18,,,percent of total billed charges,pays at 18% of total charges,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,134.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,268.8,
CLSD TX METACARPAL FX W MANIP EA,3780113,CDM,450,RC,,,Outpatient,,,266.2,159.72,,47.92,18,,,percent of total billed charges,pays at 18% of total charges,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.1,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,199.65,75,,,percent of total billed charges,75% of total billed charges,133.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,266.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,266.2,
CLSD TX CARPOMETACARPAL DSLCTN,3780115,CDM,450,RC,,,Outpatient,,,310,186,,55.8,18,,,percent of total billed charges,pays at 18% of total charges,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,310,
CLSD TX PHALANGEL SHAFT FX WO MANIP,3780118,CDM,450,RC,,,Outpatient,,,238.48,143.09,,42.93,18,,,percent of total billed charges,pays at 18% of total charges,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.24,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,178.86,75,,,percent of total billed charges,75% of total billed charges,119.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,143.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,238.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,214.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.37,238.48,
CLSD TX PHALANGEL SHAFT FX W MANIP,3780119,CDM,450,RC,,,Outpatient,,,181.5,108.9,,32.67,18,,,percent of total billed charges,pays at 18% of total charges,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,136.13,75,,,percent of total billed charges,75% of total billed charges,90.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.44,181.5,
CLSD TX DISTAL PHLNGL FX W MANIP EACH,3780123,CDM,450,RC,,,Outpatient,,,181.5,108.9,,32.67,18,,,percent of total billed charges,pays at 18% of total charges,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,136.13,75,,,percent of total billed charges,75% of total billed charges,90.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.44,181.5,
CLSD TX FINGER DISLCTN  W MANIP NO ANES,3780124,CDM,450,RC,,,Outpatient,,,208.12,124.87,,37.46,18,,,percent of total billed charges,pays at 18% of total charges,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.06,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,156.09,75,,,percent of total billed charges,75% of total billed charges,104.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,166.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,208.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,187.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.61,208.12,
CLSD TX INTERPHALANGEAL DSLCTN,3780125,CDM,450,RC,,,Outpatient,,,455.18,273.11,,81.93,18,,,percent of total billed charges,pays at 18% of total charges,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.59,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,341.39,75,,,percent of total billed charges,75% of total billed charges,227.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455.18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.33,455.18,
CLSD TX  METATARSOPHAL JT DISLC W ANESTH,3780130,CDM,450,RC,,,Outpatient,,,2985,1791,,537.3,18,,,percent of total billed charges,pays at 18% of total charges,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1492.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,2238.75,75,,,percent of total billed charges,75% of total billed charges,1492.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1791,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2283.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1343.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2089.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1791,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2089.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1432.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2985,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2686.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.75,2985,
CLSD TX FEMUR SHAFT FX,3780131,CDM,450,RC,,,Outpatient,,,1113.82,668.29,,200.49,18,,,percent of total billed charges,pays at 18% of total charges,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,556.91,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,835.37,75,,,percent of total billed charges,75% of total billed charges,556.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1113.82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1002.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.54,1113.82,
CLSD TX HIP DISLOCATION,3780140,CDM,450,RC,,,Outpatient,,,268.8,161.28,,48.38,18,,,percent of total billed charges,pays at 18% of total charges,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,134.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,268.8,
CLSD TX TIBIAL SHAFT FX W MANIP,3780145,CDM,450,RC,,,Outpatient,,,1113.82,668.29,,200.49,18,,,percent of total billed charges,pays at 18% of total charges,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,556.91,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,835.37,75,,,percent of total billed charges,75% of total billed charges,556.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1113.82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1002.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.54,1113.82,
CLSD TX PRXML FIBULA OR SHAFT FX,3780147,CDM,450,RC,,,Outpatient,,,605.43,363.26,,108.98,18,,,percent of total billed charges,pays at 18% of total charges,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,454.07,75,,,percent of total billed charges,75% of total billed charges,302.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.87,605.43,
CLSD TX DISTAL FIBULAR FX W MANIP,3780151,CDM,450,RC,,,Outpatient,,,268.8,161.28,,48.38,18,,,percent of total billed charges,pays at 18% of total charges,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,134.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,268.8,
HUMERAL CONDYLAR FX WITH MANIPULATION,3780152,CDM,450,RC,,,Outpatient,,,2998,1798.8,,539.64,18,,,percent of total billed charges,pays at 18% of total charges,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1499,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,2248.5,75,,,percent of total billed charges,75% of total billed charges,1499,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1798.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2293.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2098.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1798.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1139.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2098.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1439.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2998,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2698.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.79,2998,
CLSD TX ANKLE BIMALLEOLAR FX W MANIP,3780153,CDM,450,RC,,,Outpatient,,,605.43,363.26,,108.98,18,,,percent of total billed charges,pays at 18% of total charges,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,454.07,75,,,percent of total billed charges,75% of total billed charges,302.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.87,605.43,
TX ANKLE TRIMALLEOLAR FX /W MANIP,3780155,CDM,450,RC,,,Outpatient,,,605.43,363.26,,108.98,18,,,percent of total billed charges,pays at 18% of total charges,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,454.07,75,,,percent of total billed charges,75% of total billed charges,302.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,484.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,463.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,363.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,423.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,605.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.87,605.43,
CLSD TX DISTAL TIBIAL FX W MANIP,3780157,CDM,450,RC,,,Outpatient,,,1113.82,668.29,,200.49,18,,,percent of total billed charges,pays at 18% of total charges,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,556.91,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,835.37,75,,,percent of total billed charges,75% of total billed charges,556.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,891.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,852.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,668.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,779.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1113.82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1002.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.54,1113.82,
CLSD TX ANKLE DISLOCATION,3780158,CDM,450,RC,,,Outpatient,,,266.2,159.72,,47.92,18,,,percent of total billed charges,pays at 18% of total charges,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.1,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,199.65,75,,,percent of total billed charges,75% of total billed charges,133.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,186.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,266.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,266.2,
RMVL FOREIGN BODY FOOT SQ,3780164,CDM,450,RC,,,Outpatient,,,701.63,420.98,,126.29,18,,,percent of total billed charges,pays at 18% of total charges,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,350.82,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,526.22,75,,,percent of total billed charges,75% of total billed charges,350.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,561.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,420.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,536.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,491.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,266.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,491.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,701.63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,631.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.95,701.63,
CLSD TX METATARSAL FX W MANIP EA,3780168,CDM,450,RC,,,Outpatient,,,266.2,159.72,,47.92,18,,,percent of total billed charges,pays at 18% of total charges,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.1,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,199.65,75,,,percent of total billed charges,75% of total billed charges,133.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,212.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,186.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,266.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,239.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.71,266.2,
CLSD TX PHALANGEAL FX EA,3780172,CDM,450,RC,,,Outpatient,,,189.2,113.52,,34.06,18,,,percent of total billed charges,pays at 18% of total charges,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.6,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,141.9,75,,,percent of total billed charges,75% of total billed charges,94.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.65,189.2,
CLSD TX NASAL FX W MANPLTN,3780173,CDM,450,RC,,,Outpatient,,,3043,1825.8,,547.74,18,,,percent of total billed charges,pays at 18% of total charges,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,547.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1521.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,2282.25,75,,,percent of total billed charges,75% of total billed charges,1521.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2434.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1825.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2327.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1369.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2130.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1825.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1156.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2130.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1460.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3043,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2738.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,476.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.84,3043,
CLSD TX MEDIAL MALLEOLUS FX W MANIP,3780175,CDM,450,RC,,,Outpatient,,,2298.58,1379.15,,413.74,18,,,percent of total billed charges,pays at 18% of total charges,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,413.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1149.29,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1723.94,75,,,percent of total billed charges,75% of total billed charges,1149.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1838.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1379.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1758.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1034.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1609.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1379.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,873.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1609.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2298.58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2068.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.19,2298.58,
KNEE DISLOCATION,3780177,CDM,450,RC,,,Outpatient,,,295.68,177.41,,53.22,18,,,percent of total billed charges,pays at 18% of total charges,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.84,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,221.76,75,,,percent of total billed charges,75% of total billed charges,147.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,206.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,295.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,295.68,
CLSD TX PATELLAR DISLOCATION,3780178,CDM,450,RC,,,Outpatient,,,295.68,177.41,,53.22,18,,,percent of total billed charges,pays at 18% of total charges,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.84,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,221.76,75,,,percent of total billed charges,75% of total billed charges,147.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,206.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,295.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,295.68,
CLSD TX RADIAL HEAD SUBLUX,3780182,CDM,450,RC,,,Outpatient,,,310,186,,55.8,18,,,percent of total billed charges,pays at 18% of total charges,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,310,
CLSD TX SHOULDER DISLOCATION WO ANES,3780184,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
NASAL FX REDUCTION WITHOUT MANIPULATION,3780185,CDM,450,RC,,,Outpatient,,,1997.52,1198.51,,359.55,18,,,percent of total billed charges,pays at 18% of total charges,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,359.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,998.76,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1498.14,75,,,percent of total billed charges,75% of total billed charges,998.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1598.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1198.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1528.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1398.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1198.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,759.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1398.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1997.52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1797.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.01,1997.52,
CLSD TX ACROMOCLAVICAL DISLC W/MANPU,3780187,CDM,450,RC,23545,HCPCS,Outpatient,,,487,292.2,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,487,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,438.16,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,365.25,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,389.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,372.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,219.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,340.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,185.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,340.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,438.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,487,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,185.06,666.19,
NASAL PACKING,3780189,CDM,272,RC,,,Outpatient,,,135.9,81.54,,24.46,18,,,percent of total billed charges,pays at 18% of total charges,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.95,50,,,percent of total billed charges,pays at 50% of total billed charges,95.13,70,,,percent of total billed charges,70% of total billed charges,101.93,75,,,percent of total billed charges,75% of total billed charges,67.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.3,135.9,
PACK ER TRAUMA,3780190,CDM,272,RC,,,Outpatient,,,105.77,63.46,,19.04,18,,,percent of total billed charges,pays at 18% of total charges,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.89,50,,,percent of total billed charges,pays at 50% of total billed charges,74.04,70,,,percent of total billed charges,70% of total billed charges,79.33,75,,,percent of total billed charges,75% of total billed charges,52.89,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,95.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.57,105.77,
KIT EMERGENCY CRICOTHYROIDOTOMY,3780191,CDM,272,RC,,,Outpatient,,,288.68,173.21,,51.96,18,,,percent of total billed charges,pays at 18% of total charges,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.34,50,,,percent of total billed charges,pays at 50% of total billed charges,202.08,70,,,percent of total billed charges,70% of total billed charges,216.51,75,,,percent of total billed charges,75% of total billed charges,144.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,173.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,202.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,202.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,288.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,259.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.24,288.68,
INTRMDT REPR FACE/EAR/EYELID/NOSE/LIP,3780201,CDM,450,RC,12054,HCPCS,Outpatient,,,784.65,470.79,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,784.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,588.49,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,627.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,600.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,353.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,549.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,470.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,298.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,549.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,376.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,706.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,298.17,1200.61,
EXPLORATION PENETRATING WOUND SPX EXTREM,3780202,CDM,450,RC,20103,HCPCS,Outpatient,,,1408.08,844.85,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1408.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1056.06,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1077.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,633.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,985.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,844.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,535.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,985.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,675.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1267.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1408.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,535.07,4825.85,
RMVL FOREIGN BODY CMPLCTD,3780215,CDM,450,RC,,,Outpatient,,,2441.1,1464.66,,439.4,18,,,percent of total billed charges,pays at 18% of total charges,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1220.55,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1830.83,75,,,percent of total billed charges,75% of total billed charges,1220.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1952.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1464.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1867.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1708.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1464.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,927.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1708.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1171.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2441.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2196.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.52,2441.1,
CONTROL NASAL HEMORRHAGE,3780302,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
RMVL NASAL FOREIGN BODY,3780314,CDM,450,RC,,,Outpatient,,,163.44,98.06,,29.42,18,,,percent of total billed charges,pays at 18% of total charges,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.72,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,122.58,75,,,percent of total billed charges,75% of total billed charges,81.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.45,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.61,163.44,
DRNG FINGER ABSCESS,3780516,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
DRAINAGE OF MOUTH LESION-COMPLEX,3780518,CDM,450,RC,,,Outpatient,,,1017,610.2,,183.06,18,,,percent of total billed charges,pays at 18% of total charges,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,508.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,762.75,75,,,percent of total billed charges,75% of total billed charges,508.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,610.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,778.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,610.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1017,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,915.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.36,1017,
ASPIRATION &/OR INJ JOINT OR BURSA,3780611,CDM,450,RC,,,Outpatient,,,591,354.6,,106.38,18,,,percent of total billed charges,pays at 18% of total charges,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,443.25,75,,,percent of total billed charges,75% of total billed charges,295.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,472.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,354.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,452.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,413.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,354.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,413.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,591,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,531.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.61,591,
PHILADELPHIA C-COLLAR,3780808,CDM,274,RC,L0120,HCPCS,Outpatient,,,151,90.6,,100.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,50,,,percent of total billed charges,pays at 50% of total billed charges,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,51.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.61,350,,,Fee Schedule,350% of CMS OPPS Rate,29.03,102,,,Fee Schedule,102% of CMS OPPS Rate,151,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,65.46,230,,,Fee Schedule,230% of CMS OPPS Rate,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,28.46,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,23.66,151,
GASTRIC LAVAGE KIT,3780810,CDM,272,RC,,,Outpatient,,,174.5,104.7,,31.41,18,,,percent of total billed charges,pays at 18% of total charges,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.25,50,,,percent of total billed charges,pays at 50% of total billed charges,122.15,70,,,percent of total billed charges,70% of total billed charges,130.88,75,,,percent of total billed charges,75% of total billed charges,87.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,139.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,122.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,174.5,
RMVL OBSTRCTV MATERIAL FROM GI TUBE,3780814,CDM,450,RC,,,Outpatient,,,1530.63,918.38,,275.51,18,,,percent of total billed charges,pays at 18% of total charges,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765.32,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1147.97,75,,,percent of total billed charges,75% of total billed charges,765.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1224.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1071.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,918.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,581.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1071.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1530.63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1377.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.85,1530.63,
QUIK PACE(EXTERNAL PACER),3780836,CDM,271,RC,,,Outpatient,,,189,113.4,,34.02,18,,,percent of total billed charges,pays at 18% of total charges,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,50,,,percent of total billed charges,pays at 50% of total billed charges,132.3,70,,,percent of total billed charges,70% of total billed charges,141.75,75,,,percent of total billed charges,75% of total billed charges,94.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,170.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.62,189,
ASP OR INJ SMALL JOINT/ BURSA  FNGR/TOE,3780903,CDM,450,RC,,,Outpatient,,,317.9,190.74,,57.22,18,,,percent of total billed charges,pays at 18% of total charges,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.95,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,238.43,75,,,percent of total billed charges,75% of total billed charges,158.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,286.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.81,317.9,
ARTHRCNTS ASP OR INJ JOINT OR BURSA,3780904,CDM,450,RC,,,Outpatient,,,807.2,484.32,,145.3,18,,,percent of total billed charges,pays at 18% of total charges,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,403.6,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,605.4,75,,,percent of total billed charges,75% of total billed charges,403.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,807.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.49,807.2,
CLSD TX ELBOW DISLOCATION,3781010,CDM,450,RC,,,Outpatient,,,241.92,145.15,,43.55,18,,,percent of total billed charges,pays at 18% of total charges,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.96,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,181.44,75,,,percent of total billed charges,75% of total billed charges,120.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,193.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,169.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,241.92,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,217.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.91,241.92,
CLSD TX TEMPOROMANDBLR DISLOCTN JAW,3781016,CDM,450,RC,,,Outpatient,,,250.4,150.24,,45.07,18,,,percent of total billed charges,pays at 18% of total charges,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.2,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,187.8,75,,,percent of total billed charges,75% of total billed charges,125.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,200.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,175.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,250.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,225.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.24,250.4,
APPLCTN LONG ARM SPLINT SHLDR TO HAND,3781200,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
APPLCTN SHORT ARM SPLINT FOREARM TO HAND,3781202,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
FINGER SPLINT APPLICATION,3781204,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
APPLCTN LONG LEG SPLINT THIGH TO ANKLE,3781206,CDM,450,RC,,,Outpatient,,,255.2,153.12,,45.94,18,,,percent of total billed charges,pays at 18% of total charges,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.6,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,191.4,75,,,percent of total billed charges,75% of total billed charges,127.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,255.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,229.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.99,255.2,
SHORT LEG SPLINT CALF/FOOT,3781208,CDM,450,RC,,,Outpatient,,,255.2,153.12,,45.94,18,,,percent of total billed charges,pays at 18% of total charges,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.6,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,191.4,75,,,percent of total billed charges,75% of total billed charges,127.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,255.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,229.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.99,255.2,
SHORT LEG CAST KNEE TO TOES,3781216,CDM,450,RC,,,Outpatient,,,310,186,,55.8,18,,,percent of total billed charges,pays at 18% of total charges,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,155,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,310,
CLSD TX ELBOW DISLOCATION W ANES,3781217,CDM,450,RC,,,Outpatient,,,1467.36,880.42,,264.12,18,,,percent of total billed charges,pays at 18% of total charges,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,264.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,733.68,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1100.52,75,,,percent of total billed charges,75% of total billed charges,733.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1173.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,880.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1122.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1027.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,880.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,557.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1027.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1467.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1320.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.94,1467.36,
ANOSCOPY DIAGNOSTIC,3781406,CDM,450,RC,,,Outpatient,,,221.5,132.9,,39.87,18,,,percent of total billed charges,pays at 18% of total charges,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,166.13,75,,,percent of total billed charges,75% of total billed charges,110.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,177.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,221.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,199.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.71,221.5,
REDUCTN PROCIDENTIA ANES,3781407,CDM,450,RC,,,Outpatient,,,830,498,,149.4,18,,,percent of total billed charges,pays at 18% of total charges,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,415,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,622.5,75,,,percent of total billed charges,75% of total billed charges,415,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,498,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,634.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,581,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,498,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,581,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,830,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,747,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.06,830,
CLSD REDUCTN MANDIBULAR FX W MANPLTN,3781451,CDM,450,RC,,,Outpatient,,,2775,1665,,499.5,18,,,percent of total billed charges,pays at 18% of total charges,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,499.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1387.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,2081.25,75,,,percent of total billed charges,75% of total billed charges,1387.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1665,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2122.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1942.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1665,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1054.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1942.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1332,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2775,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2497.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.84,2775,
DEBRIDEMENT OF NAIL 1 TO 5,3781720,CDM,450,RC,,,Outpatient,,,126.45,75.87,,22.76,18,,,percent of total billed charges,pays at 18% of total charges,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.23,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,94.84,75,,,percent of total billed charges,75% of total billed charges,63.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,101.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,126.45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,113.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.81,126.45,
CRITICAL CARE OVER 75 MINUTES,3782007,CDM,450,RC,99292,HCPCS,Outpatient,,,1135,681,,204.3,18,,,percent of total billed charges,pays at 18% of total charges,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.5,70,,,percent of total billed charges,70% of total billed charges,851.25,75,,,percent of total billed charges,75% of total billed charges,567.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,908,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,681,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,868.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,195.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,794.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,681,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,431.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,794.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1135,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1021.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,177.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.85,1135,
CRITICAL CARE,3782008,CDM,450,RC,99291,HCPCS,Outpatient,,,1804,1082.4,,2470.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,697.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3036.5,100,,,Case rate,pays based on per visit rate,1262.8,70,,,percent of total billed charges,70% of total billed charges,1353,75,,,percent of total billed charges,75% of total billed charges,1256.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1443.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2442.77,350,,,Fee Schedule,350% of CMS OPPS Rate,711.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1380.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,310.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,811.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1262.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1082.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3099,100,,,Case rate,Pays based on per visit ,1262.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3407,100,,,Case rate,pays based on per visit rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,282.69,3407,
VAGINAL DELIVERY,3782009,CDM,450,RC,,,Outpatient,,,4561,2736.6,,820.98,18,,,percent of total billed charges,pays at 18% of total charges,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2280.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,3420.75,75,,,percent of total billed charges,75% of total billed charges,2280.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3648.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2736.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3489.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2052.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3192.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2736.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1733.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3192.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2189.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4561,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4104.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.71,4561,
TRAUMA RESPONSE TEAM LEVEL 1,3782010,CDM,683,RC,G0390,HCPCS,Outpatient,,,8250,4950,,3705.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1952.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5775,70,,,percent of total billed charges,70% of total billed charges,6187.5,75,,,percent of total billed charges,75% of total billed charges,1884.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3664.02,350,,,Fee Schedule,350% of CMS OPPS Rate,1067.8,103,,,Fee Schedule,103% of CMS OPPS Rate,6311.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3712.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5775,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3135,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5775,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2407.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,7425,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,7425,
TRAUMA RESPONSE TEAM LEVEL 2,3782011,CDM,683,RC,G0390,HCPCS,Outpatient,,,5500,3300,,3705.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1952.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3850,70,,,percent of total billed charges,70% of total billed charges,4125,75,,,percent of total billed charges,75% of total billed charges,1884.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3664.02,350,,,Fee Schedule,350% of CMS OPPS Rate,1067.8,103,,,Fee Schedule,103% of CMS OPPS Rate,4207.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2475,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3850,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2090,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3850,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2407.78,100,,,Fee Schedule,100% of CMS OPPS Rate,2640,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,4950,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,4950,
TRAUMA RESPONSE TEAM LEVEL 1,3782012,CDM,683,RC,G0390,HCPCS,Outpatient,,,8250,4950,,3705.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1952.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5775,70,,,percent of total billed charges,70% of total billed charges,6187.5,75,,,percent of total billed charges,75% of total billed charges,1884.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3664.02,350,,,Fee Schedule,350% of CMS OPPS Rate,1067.8,103,,,Fee Schedule,103% of CMS OPPS Rate,6311.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3712.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5775,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3135,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5775,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2407.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,7425,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,7425,
TRAUMA RESPONSE TEAM LEVEL 1,3782013,CDM,450,RC,G0390,HCPCS,Outpatient,,,8250,4950,,3705.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1952.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,6187.5,75,,,percent of total billed charges,75% of total billed charges,1884.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3664.02,350,,,Fee Schedule,350% of CMS OPPS Rate,1067.8,103,,,Fee Schedule,103% of CMS OPPS Rate,6311.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1421.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3712.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5775,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3135,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5775,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2407.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,7425,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1292.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,7425,
TRAUMA RESPONSE TEAM LEVEL 2,3782014,CDM,450,RC,G0390,HCPCS,Outpatient,,,5500,3300,,3705.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1046.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1952.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,4125,75,,,percent of total billed charges,75% of total billed charges,1884.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3664.02,350,,,Fee Schedule,350% of CMS OPPS Rate,1067.8,103,,,Fee Schedule,103% of CMS OPPS Rate,4207.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,947.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2475,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3850,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2090,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3850,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,2407.78,100,,,Fee Schedule,100% of CMS OPPS Rate,2640,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,4950,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,861.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.85,100,,,Fee Schedule,100% of CMS OPPS Rate,861.85,4950,
ARTERIAL LINE INSERTION,3782019,CDM,450,RC,36620,HCPCS,Outpatient,,,204.12,122.47,,36.74,18,,,percent of total billed charges,pays at 18% of total charges,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.09,75,,,percent of total billed charges,75% of total billed charges,102.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,163.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,204.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.99,204.12,
CLOSURE WOUND DEHISCENCE SMPL,3782020,CDM,450,RC,,,Outpatient,,,437.8,262.68,,78.8,18,,,percent of total billed charges,pays at 18% of total charges,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.9,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,328.35,75,,,percent of total billed charges,75% of total billed charges,218.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,350.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,437.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,394.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.6,437.8,
RMVL FB EYE CONJUNCTIVA SU,3782050,CDM,450,RC,,,Outpatient,,,425.04,255.02,,76.51,18,,,percent of total billed charges,pays at 18% of total charges,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.52,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,318.78,75,,,percent of total billed charges,75% of total billed charges,212.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,425.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.6,425.04,
RMVL FB-EYE-SUBCONJUNCT/SC,3782051,CDM,450,RC,,,Outpatient,,,336,201.6,,60.48,18,,,percent of total billed charges,pays at 18% of total charges,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,252,75,,,percent of total billed charges,75% of total billed charges,168,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,336,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,302.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,336,
RMVL FB EYE-CORNEAL W/SLIT,3782052,CDM,450,RC,,,Outpatient,,,425.04,255.02,,76.51,18,,,percent of total billed charges,pays at 18% of total charges,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.52,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,318.78,75,,,percent of total billed charges,75% of total billed charges,212.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,425.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.6,425.04,
RMVL FB EYE-CORNEAL W/O SL,3782053,CDM,450,RC,,,Outpatient,,,425.04,255.02,,76.51,18,,,percent of total billed charges,pays at 18% of total charges,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.52,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,318.78,75,,,percent of total billed charges,75% of total billed charges,212.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,425.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.6,425.04,
RMVL FB EAR,3782056,CDM,450,RC,,,Outpatient,,,169.84,101.9,,30.57,18,,,percent of total billed charges,pays at 18% of total charges,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.92,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,127.38,75,,,percent of total billed charges,75% of total billed charges,84.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.61,169.84,
RMVL IMPACTED CERUMEN,3782057,CDM,450,RC,,,Outpatient,,,132.88,79.73,,23.92,18,,,percent of total billed charges,pays at 18% of total charges,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.44,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,99.66,75,,,percent of total billed charges,75% of total billed charges,66.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,119.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.82,132.88,
DRNG EXTNL EAR,3782058,CDM,450,RC,,,Outpatient,,,341,204.6,,61.38,18,,,percent of total billed charges,pays at 18% of total charges,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,170.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,341,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.43,341,
CLSD TX HIP DISLOCATION,3782063,CDM,450,RC,,,Outpatient,,,2364.8,1418.88,,425.66,18,,,percent of total billed charges,pays at 18% of total charges,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,425.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1182.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1773.6,75,,,percent of total billed charges,75% of total billed charges,1182.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1891.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1418.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1809.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1655.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1418.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,898.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1655.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1135.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2364.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2128.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.56,2364.8,
INC & DRNG PERIRECTAL ABSCESS,3782069,CDM,450,RC,,,Outpatient,,,2470.36,1482.22,,444.66,18,,,percent of total billed charges,pays at 18% of total charges,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235.18,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1852.77,75,,,percent of total billed charges,75% of total billed charges,1235.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1976.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1482.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1889.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1111.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1729.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1482.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,938.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1729.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1185.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2470.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2223.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.11,2470.36,
INC & DRNG PERIANAL ABSCESS,3782070,CDM,450,RC,,,Outpatient,,,1126.86,676.12,,202.83,18,,,percent of total billed charges,pays at 18% of total charges,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,563.43,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,845.15,75,,,percent of total billed charges,75% of total billed charges,563.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,901.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,862.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,788.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,676.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,428.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,788.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1126.86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1014.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.58,1126.86,
INC & DRNG BARTHOLIN CYST,3782071,CDM,450,RC,,,Outpatient,,,425.04,255.02,,76.51,18,,,percent of total billed charges,pays at 18% of total charges,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.52,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,318.78,75,,,percent of total billed charges,75% of total billed charges,212.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,340.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,297.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,425.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,382.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.6,425.04,
INC & DRNG SCROTAL WALL,3782072,CDM,450,RC,,,Outpatient,,,1830.4,1098.24,,329.47,18,,,percent of total billed charges,pays at 18% of total charges,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,915.2,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1372.8,75,,,percent of total billed charges,75% of total billed charges,915.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1464.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1098.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1400.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1281.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1098.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,695.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1281.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1830.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1647.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,286.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.82,1830.4,
CLSD TX METACARPAL DISLOCATION,3782077,CDM,450,RC,,,Outpatient,,,143.53,86.12,,25.84,18,,,percent of total billed charges,pays at 18% of total charges,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.77,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,107.65,75,,,percent of total billed charges,75% of total billed charges,71.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,143.53,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.49,143.53,
RMVL/ REVISION ARM/LEG CAST,3782089,CDM,450,RC,,,Outpatient,,,482.83,289.7,,86.91,18,,,percent of total billed charges,pays at 18% of total charges,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,241.42,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,362.12,75,,,percent of total billed charges,75% of total billed charges,241.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,386.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,337.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,289.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,337.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,482.83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,434.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.66,482.83,
REPAIR LIP,3782121,CDM,450,RC,,,Outpatient,,,1529.28,917.57,,275.27,18,,,percent of total billed charges,pays at 18% of total charges,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,764.64,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1146.96,75,,,percent of total billed charges,75% of total billed charges,764.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,917.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1169.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1070.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,917.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,581.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1070.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1529.28,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1376.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.64,1529.28,
REPAIR OF NAIL BED,3782132,CDM,450,RC,,,Outpatient,,,1605,963,,288.9,18,,,percent of total billed charges,pays at 18% of total charges,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,802.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1203.75,75,,,percent of total billed charges,75% of total billed charges,802.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,963,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1227.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1123.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,963,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,609.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1123.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1605,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1444.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.5,1605,
RPR TONGUE LAC 2.5 CM ANT,3782133,CDM,450,RC,,,Outpatient,,,232,139.2,,41.76,18,,,percent of total billed charges,pays at 18% of total charges,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,174,75,,,percent of total billed charges,75% of total billed charges,116,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,232,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,208.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,232,
RPR TONGUE LAC >2.6CM OR CMPLX,3782134T,CDM,450,RC,,,Outpatient,,,1478.4,887.04,,266.11,18,,,percent of total billed charges,pays at 18% of total charges,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,739.2,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1108.8,75,,,percent of total billed charges,75% of total billed charges,739.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1182.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,887.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1130.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1034.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,887.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,561.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1034.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1478.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1330.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.67,1478.4,
INC & DRNG MOUTH ABSCESS,3782135,CDM,450,RC,,,Outpatient,,,387.35,232.41,,69.72,18,,,percent of total billed charges,pays at 18% of total charges,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.68,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,290.51,75,,,percent of total billed charges,75% of total billed charges,193.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,309.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,271.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,387.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,348.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.7,387.35,
PEG TUBE CHANGE,3783000,CDM,450,RC,,,Outpatient,,,286,171.6,,51.48,18,,,percent of total billed charges,pays at 18% of total charges,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,143,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,214.5,75,,,percent of total billed charges,75% of total billed charges,143,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,200.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,286,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,257.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.82,286,
DRNG RECTAL ABCESS,3783001,CDM,450,RC,,,Outpatient,,,1235.18,741.11,,222.33,18,,,percent of total billed charges,pays at 18% of total charges,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.59,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,926.39,75,,,percent of total billed charges,75% of total billed charges,617.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,741.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,944.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1235.18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1111.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.55,1235.18,
PARACENTESIS/PERITONEAL L,3783003,CDM,450,RC,,,Outpatient,,,486.72,292.03,,87.61,18,,,percent of total billed charges,pays at 18% of total charges,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,243.36,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,365.04,75,,,percent of total billed charges,75% of total billed charges,243.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,389.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,372.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,340.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,184.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,340.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,486.72,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,438.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,486.72,
BLADDER IRRIGATION,3783004,CDM,450,RC,51700,HCPCS,Outpatient,,,254,152.4,,691.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,195.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,467.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,190.5,75,,,percent of total billed charges,75% of total billed charges,351.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,203.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.68,350,,,Fee Schedule,350% of CMS OPPS Rate,199.23,103,,,Fee Schedule,103% of CMS OPPS Rate,194.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,96.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,177.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,449.27,100,,,Fee Schedule,100% of CMS OPPS Rate,121.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,228.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,39.8,691.48,
SPINAL FLUID TAP,3783008,CDM,450,RC,,,Outpatient,,,661.68,397.01,,119.1,18,,,percent of total billed charges,pays at 18% of total charges,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.84,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,496.26,75,,,percent of total billed charges,75% of total billed charges,330.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,529.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,506.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,661.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,595.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.69,661.68,
INJCT EPIDURAL OF BLOOD/ CLOT PATCH,3783009,CDM,450,RC,,,Outpatient,,,570.47,342.28,,102.68,18,,,percent of total billed charges,pays at 18% of total charges,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285.24,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,427.85,75,,,percent of total billed charges,75% of total billed charges,285.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,456.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,342.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,436.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,399.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,399.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,570.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,513.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.39,570.47,
HEMORRHOIDECTOMY EXTERNAL,3783010,CDM,450,RC,,,Outpatient,,,366.04,219.62,,65.89,18,,,percent of total billed charges,pays at 18% of total charges,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.02,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,274.53,75,,,percent of total billed charges,75% of total billed charges,183.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,219.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,256.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,366.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,329.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.36,366.04,
REPLACEMENT OF G TUBE NO GUIDANCE,3783011,CDM,450,RC,,,Outpatient,,,528.15,316.89,,95.07,18,,,percent of total billed charges,pays at 18% of total charges,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264.08,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,396.11,75,,,percent of total billed charges,75% of total billed charges,264.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,404.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,369.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,369.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,475.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.76,528.15,
INJECTION SQ OR IM,3783014,CDM,450,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,97.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
NG INSERTION/LAVAGE,3783016,CDM,450,RC,,,Outpatient,,,217.08,130.25,,39.07,18,,,percent of total billed charges,pays at 18% of total charges,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.54,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,162.81,75,,,percent of total billed charges,75% of total billed charges,108.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,217.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,195.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.02,217.08,
CPR,3783017,CDM,450,RC,92950,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,260.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
PACER EXTERNAL,3783018,CDM,450,RC,92953,HCPCS,Outpatient,,,618.4,371.04,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,463.8,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,494.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,473.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,278.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,432.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,371.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,234.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,432.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,296.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,556.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,96.9,1892.75,
CARDIOVERSION ELECTIVE,3783019,CDM,480,RC,92960,HCPCS,Outpatient,,,1452,871.2,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges,1089,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1110.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,653.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,696.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,1892.75,
NEWBORN RESUSCITATION,3783020,CDM,450,RC,99465,HCPCS,Outpatient,,,537.6,322.56,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,403.2,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,430.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,537.6,103,,,Fee Schedule,103% of CMS OPPS Rate,411.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,241.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,376.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,322.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,204.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,376.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,258.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,483.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,1892.75,
Ultrasound of bladder to measure urine capacity,3783021,CDM,450,RC,51798,HCPCS,Outpatient,,,189.9,113.94,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,142.43,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,151.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,145.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,85.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,72.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,91.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,170.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,184.98,
INTUBATION ENDOTRACHEAL,3783022,CDM,450,RC,,,Outpatient,,,556.56,333.94,,100.18,18,,,percent of total billed charges,pays at 18% of total charges,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,278.28,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,417.42,75,,,percent of total billed charges,75% of total billed charges,278.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,425.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,389.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,333.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,389.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,556.56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,500.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.21,556.56,
TRACHEOTOMY-TUBE CHANGE,3783023,CDM,450,RC,,,Outpatient,,,347.6,208.56,,62.57,18,,,percent of total billed charges,pays at 18% of total charges,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.8,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,260.7,75,,,percent of total billed charges,75% of total billed charges,173.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,278.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,208.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,265.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,243.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,243.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,347.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,312.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,347.6,
THORACENTESIS,3783025,CDM,450,RC,,,Outpatient,,,604.8,362.88,,108.86,18,,,percent of total billed charges,pays at 18% of total charges,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,453.6,75,,,percent of total billed charges,75% of total billed charges,302.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,483.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,362.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,462.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,423.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,423.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,604.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,544.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.77,604.8,
TUBE THORACOSTOMY,3783027,CDM,450,RC,,,Outpatient,,,1411,846.6,,253.98,18,,,percent of total billed charges,pays at 18% of total charges,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,253.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1058.25,75,,,percent of total billed charges,75% of total billed charges,705.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,846.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1079.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,987.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,846.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,536.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,987.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1411,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1269.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.1,1411,
PLEURAL DRNG PERC WITH CATH AND GUIDANCE,3783028,CDM,450,RC,,,Outpatient,,,1496.38,897.83,,269.35,18,,,percent of total billed charges,pays at 18% of total charges,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,269.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,748.19,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1122.29,75,,,percent of total billed charges,75% of total billed charges,748.19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1197.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,897.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1144.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1047.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,568.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1047.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1496.38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1346.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.48,1496.38,
INCISION THROMBOSED HEMORRHOID EXTERNAL,3783031,CDM,450,RC,,,Outpatient,,,492,295.2,,88.56,18,,,percent of total billed charges,pays at 18% of total charges,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,246,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,369,75,,,percent of total billed charges,75% of total billed charges,246,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,295.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,376.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,344.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,186.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,344.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,492,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,442.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.1,492,
CENTRAL LINE GRTR THAN 5 YRS,3783034,CDM,450,RC,,,Outpatient,,,2004,1202.4,,360.72,18,,,percent of total billed charges,pays at 18% of total charges,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1002,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1503,75,,,percent of total billed charges,75% of total billed charges,1002,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1603.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1202.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1533.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,901.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1402.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1202.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,761.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1402.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2004,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1803.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.03,2004,
Immunization administration by a medical assistant or nurse,3783035,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
PULSE OX SGL,3783038,CDM,460,RC,94760,HCPCS,Outpatient,,,61.2,36.72,,11.02,18,,,percent of total billed charges,pays at 18% of total charges,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,70,,,percent of total billed charges,70% of total billed charges,45.9,75,,,percent of total billed charges,75% of total billed charges,30.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,42.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.59,422,
GLUCOSE ACCUDATA,3783041,CDM,300,RC,82962,HCPCS,Outpatient,,,11.25,6.75,,11.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges,8.44,75,,,percent of total billed charges,75% of total billed charges,5.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.48,350,,,Fee Schedule,350% of CMS OPPS Rate,3.34,102,,,Fee Schedule,102% of CMS OPPS Rate,8.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of UHC Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,7.54,230,,,Fee Schedule,230% of CMS OPPS Rate,5.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,11.61,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",3783043,CDM,450,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,188.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",3783044,CDM,450,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,136.34,
HYDRATION INFUSION INITIAL HR,3783045,CDM,450,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,3783046,CDM,450,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,136.34,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3783047,CDM,450,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",3783048,CDM,450,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,148.5,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,3783049,CDM,450,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,247.5,
CONCURRENT NONCHEMO INFUSION ADDL HR,3783050,CDM,450,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,64.35,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3783051,CDM,450,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
INSERT TEMP INDWELL BLADDER CATH,3783052,CDM,450,RC,51702,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",3783055,CDM,450,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
INJECTION SQ OR IM,3783059,CDM,450,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",3783062,CDM,450,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
BLEPHAROTOMY DRN ABS EYLD,3783063,CDM,450,RC,,,Outpatient,,,360,216,,64.8,18,,,percent of total billed charges,pays at 18% of total charges,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,270,75,,,percent of total billed charges,75% of total billed charges,180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,360,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,360,
CHANGE OF CYSTOSTOMY TUBE,3783065,CDM,450,RC,51705,HCPCS,Outpatient,,,457.53,274.52,,691.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,457.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,195.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,195.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,467.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,343.15,75,,,percent of total billed charges,75% of total billed charges,351.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,366.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.68,350,,,Fee Schedule,350% of CMS OPPS Rate,199.23,103,,,Fee Schedule,103% of CMS OPPS Rate,350.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,205.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,320.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,320.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,449.27,100,,,Fee Schedule,100% of CMS OPPS Rate,219.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,411.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,457.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,691.48,
THORACENTESIS NDL OR CATH ASP GUIDANCE,3783066,CDM,450,RC,,,Outpatient,,,1354.55,812.73,,243.82,18,,,percent of total billed charges,pays at 18% of total charges,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,243.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,677.28,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1015.91,75,,,percent of total billed charges,75% of total billed charges,677.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1083.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,812.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1036.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,948.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,812.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1354.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1219.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.26,1354.55,
REPAIR TENDON FINGER (ANY),3783067,CDM,450,RC,,,Outpatient,,,5987,3592.2,,1077.66,18,,,percent of total billed charges,pays at 18% of total charges,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1077.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2993.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,4490.25,75,,,percent of total billed charges,75% of total billed charges,2993.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4789.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3592.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4580.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2694.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4190.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3592.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4190.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2873.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5987,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5388.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,938.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.16,5987,
ECHO FOLLOWUP LIMITED,3783308,CDM,483,RC,93308,HCPCS,Outpatient,,,631,378.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,482.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,567.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,98.88,1196,
CLSD TX SHOULDER DISLCTN W MANIP & ANES,3783650,CDM,450,RC,,,Outpatient,,,2662.8,1597.68,,479.3,18,,,percent of total billed charges,pays at 18% of total charges,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,479.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1331.4,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1997.1,75,,,percent of total billed charges,75% of total billed charges,1331.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2130.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1597.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2037.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1863.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1597.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1863.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1278.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2662.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2396.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,417.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.26,2662.8,
One sided or limited bilateral study,3783971,CDM,920,RC,93971,HCPCS,Outpatient,,,336,201.6,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,235.2,70,,,percent of total billed charges,70% of total billed charges,252,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,257.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,151.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,340,100,,,Case rate,Pays based on per visit ,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,161.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.65,343.95,
PENILE INJECTION,3784235,CDM,450,RC,,,Outpatient,,,451.9,271.14,,81.34,18,,,percent of total billed charges,pays at 18% of total charges,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225.95,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,338.93,75,,,percent of total billed charges,75% of total billed charges,225.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,361.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,271.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,451.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,406.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.81,451.9,
LYSIS PENILE ADHESION,3784450,CDM,450,RC,,,Outpatient,,,2505,1503,,450.9,18,,,percent of total billed charges,pays at 18% of total charges,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,450.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1252.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1878.75,75,,,percent of total billed charges,75% of total billed charges,1252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2004,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1503,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1916.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1753.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1503,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1753.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1202.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2505,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2254.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.53,2505,
CYSTOURETHROSCOPY ONLY,3785200,CDM,450,RC,,,Outpatient,,,2505,1503,,450.9,18,,,percent of total billed charges,pays at 18% of total charges,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,450.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1252.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1878.75,75,,,percent of total billed charges,75% of total billed charges,1252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2004,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1503,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1916.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1753.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1503,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1753.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1202.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2505,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2254.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.53,2505,
HEALTH & BEHAVR ASSMNT PRODUCTIVITY ONLY,3786150,CDM,918,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
IRIDOTOMY,3786500,CDM,450,RC,,,Outpatient,,,667.2,400.32,,120.1,18,,,percent of total billed charges,pays at 18% of total charges,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.6,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,500.4,75,,,percent of total billed charges,75% of total billed charges,333.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,533.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,467.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,400.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,667.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,600.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.55,667.2,
US OPHTHALMIC,3786512,CDM,402,RC,,,Outpatient,,,246.58,147.95,,44.38,18,,,percent of total billed charges,pays at 18% of total charges,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.29,50,,,percent of total billed charges,pays at 50% of total billed charges,172.61,70,,,percent of total billed charges,70% of total billed charges,184.94,75,,,percent of total billed charges,75% of total billed charges,123.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,197.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,172.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,246.58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,221.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.64,446,
REMOVAL OF FOREIGN BODY UNDER ANESTHESIA,3786513,CDM,450,RC,,,Outpatient,,,923.5,554.1,,166.23,18,,,percent of total billed charges,pays at 18% of total charges,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,461.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,692.63,75,,,percent of total billed charges,75% of total billed charges,461.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,738.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,554.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,706.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,646.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,554.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,923.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,831.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.71,923.5,
REMOVAL OF FOREIGN BODY UNDER ANESTHESIA,3786514,CDM,450,RC,,,Outpatient,,,923.5,554.1,,166.23,18,,,percent of total billed charges,pays at 18% of total charges,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,461.75,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,692.63,75,,,percent of total billed charges,75% of total billed charges,461.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,738.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,554.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,706.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,646.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,554.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,923.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,831.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.71,923.5,
US LMTD SOFT TISSUE CHEST WALL/UPPR BACK,3786604,CDM,402,RC,76604,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
NEEDLE PLCMNT FOR INTRAOSSEOUS INFUSION,3786680,CDM,450,RC,36680,HCPCS,Outpatient,,,216,129.6,,1215.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,216,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,672.86,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,162,75,,,percent of total billed charges,75% of total billed charges,617.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1201.37,350,,,Fee Schedule,350% of CMS OPPS Rate,216,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,789.47,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,216,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,1215.1,
NEEDLE INTRAOSSEOUS,3786682,CDM,272,RC,,,Outpatient,,,81.75,49.05,,14.72,18,,,percent of total billed charges,pays at 18% of total charges,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.88,50,,,percent of total billed charges,pays at 50% of total billed charges,57.23,70,,,percent of total billed charges,70% of total billed charges,61.31,75,,,percent of total billed charges,75% of total billed charges,40.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.81,81.75,
CATHETERIZATION OF UMBILICAL VEIN,3786704,CDM,450,RC,,,Outpatient,,,136,81.6,,24.48,18,,,percent of total billed charges,pays at 18% of total charges,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,102,75,,,percent of total billed charges,75% of total billed charges,68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,136,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,136,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,3786705,CDM,402,RC,76705,HCPCS,Outpatient,,,307.34,184.4,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,215.14,70,,,percent of total billed charges,70% of total billed charges,230.51,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,235.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,138.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,276.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,446,
Ultrasound of back wall of the abdomen with limited areas viewed,3786775,CDM,402,RC,76775,HCPCS,Outpatient,,,336.25,201.75,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,235.38,70,,,percent of total billed charges,70% of total billed charges,252.19,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,269,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,257.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,151.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,235.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,161.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,302.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.69,446,
Ultrasound of fetus with limited views,3786815,CDM,402,RC,76815,HCPCS,Outpatient,,,311.4,186.84,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,217.98,70,,,percent of total billed charges,70% of total billed charges,233.55,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,249.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,238.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,217.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,149.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,280.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.8,446,
Ultrasound of the pelvis through vagina,3786830,CDM,402,RC,76830,HCPCS,Outpatient,,,397.21,238.33,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,278.05,70,,,percent of total billed charges,70% of total billed charges,297.91,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,303.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,178.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,278.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,190.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,357.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.24,446,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",3786882,CDM,402,RC,76882,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
US GUIDED NEEDLE PLACMNT,3786942,CDM,402,RC,76942,HCPCS,Outpatient,,,62,37.2,,11.16,18,,,percent of total billed charges,pays at 18% of total charges,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,446,
REPAIR TENDON HEEL/FOOT,3787650,CDM,450,RC,,,Outpatient,,,6262.5,3757.5,,1127.25,18,,,percent of total billed charges,pays at 18% of total charges,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1127.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3131.25,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,4696.88,75,,,percent of total billed charges,75% of total billed charges,3131.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5010,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3757.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4790.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2818.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4383.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3757.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4383.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3006,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6262.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5636.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,981.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,981.33,6262.5,
CANTHOTOMY,3787715,CDM,450,RC,67715,HCPCS,Outpatient,,,4533,2719.8,,6804,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4533,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1922.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1922.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3693.16,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,3399.75,75,,,percent of total billed charges,75% of total billed charges,3459.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3626.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6727.12,350,,,Fee Schedule,350% of CMS OPPS Rate,1960.47,103,,,Fee Schedule,103% of CMS OPPS Rate,3467.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2039.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3173.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2719.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3173.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,4420.68,100,,,Fee Schedule,100% of CMS OPPS Rate,2175.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,4079.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4533,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.02,6804,
EKG ER,3788030,CDM,730,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.05,70,,,percent of total billed charges,70% of total billed charges,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,373,
EKG ER PRODUCTIVITY ONLY,3788030E,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
EKG ER,3788030E,CDM,730,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.05,70,,,percent of total billed charges,70% of total billed charges,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,373,
ER LEVEL I,3788034,CDM,450,RC,99281,HCPCS,Outpatient,,,290,174,,241.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,317.11,100,,,Case rate,pays based on per visit rate,203,70,,,percent of total billed charges,70% of total billed charges,217.5,75,,,percent of total billed charges,75% of total billed charges,122.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.92,350,,,Fee Schedule,350% of CMS OPPS Rate,69.62,103,,,Fee Schedule,103% of CMS OPPS Rate,221.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,130.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,156,100,,,Case rate,Pays based on per visit ,203,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,157,100,,,Fee Schedule,100% of CMS OPPS Rate,213,100,,,Case rate,pays based on per visit rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,261,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,45.44,317.11,
ER LEVEL II,3788035,CDM,450,RC,99282,HCPCS,Outpatient,,,525,315,,449.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,582.83,100,,,Case rate,pays based on per visit rate,367.5,70,,,percent of total billed charges,70% of total billed charges,393.75,75,,,percent of total billed charges,75% of total billed charges,228.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444.46,350,,,Fee Schedule,350% of CMS OPPS Rate,129.52,103,,,Fee Schedule,103% of CMS OPPS Rate,401.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,260,100,,,Case rate,Pays based on per visit ,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,292.07,100,,,Fee Schedule,100% of CMS OPPS Rate,315,100,,,Case rate,pays based on per visit rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of CMS OPPS Rate,82.27,582.83,
"Emergency department visit, moderately severe problem",3788038,CDM,450,RC,99283,HCPCS,Outpatient,,,925,555,,788.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,222.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1017.27,100,,,Case rate,pays based on per visit rate,647.5,70,,,percent of total billed charges,70% of total billed charges,693.75,75,,,percent of total billed charges,75% of total billed charges,400.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,740,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,779.64,350,,,Fee Schedule,350% of CMS OPPS Rate,227.21,103,,,Fee Schedule,103% of CMS OPPS Rate,707.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,159.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,416.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,647.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,555,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,580,100,,,Case rate,Pays based on per visit ,647.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,512.33,100,,,Fee Schedule,100% of CMS OPPS Rate,798,100,,,Case rate,pays based on per visit rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,832.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,222.75,100,,,Fee Schedule,100% of CMS OPPS Rate,144.95,1017.27,
"Emergency department visit, problem of high seVERITY|COMMERCIAL",3788039,CDM,450,RC,99284,HCPCS,Outpatient,,,1500,900,,1228.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,346.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,346.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1602.33,100,,,Case rate,pays based on per visit rate,1050,70,,,percent of total billed charges,70% of total billed charges,1125,75,,,percent of total billed charges,75% of total billed charges,624.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1214.22,350,,,Fee Schedule,350% of CMS OPPS Rate,353.85,103,,,Fee Schedule,103% of CMS OPPS Rate,1147.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,258.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,675,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1050,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1247,100,,,Case rate,Pays based on per visit ,1050,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,797.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1434,100,,,Case rate,pays based on per visit rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1350,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,346.92,100,,,Fee Schedule,100% of CMS OPPS Rate,235.05,1602.33,
"Emergency department visit, problem with significant threat to life or function",3788040,CDM,450,RC,99285,HCPCS,Outpatient,,,2200,1320,,1763.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2297.94,100,,,Case rate,pays based on per visit rate,1540,70,,,percent of total billed charges,70% of total billed charges,1650,75,,,percent of total billed charges,75% of total billed charges,896.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1744,350,,,Fee Schedule,350% of CMS OPPS Rate,508.25,103,,,Fee Schedule,103% of CMS OPPS Rate,1683,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,379.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,990,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1540,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1320,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2120,100,,,Case rate,Pays based on per visit ,1540,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2438,100,,,Case rate,pays based on per visit rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1980,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,344.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,498.28,100,,,Fee Schedule,100% of CMS OPPS Rate,344.74,2438,
V ER OBSERVATION ROOM PER 1 HR,3788041,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
ER WALK OUT PRIOR TO TRIAGE NO CHARGE,3788042,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Collection of venous blood by venipuncture,3788043,CDM,300,RC,36415,HCPCS,Outpatient,,,18.36,11.02,,30.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,12.85,70,,,percent of total billed charges,70% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.99,350,,,Fee Schedule,350% of CMS OPPS Rate,8.74,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,230,,,Fee Schedule,230% of CMS OPPS Rate,8.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,30.33,
ER PSYCH OBSERVE ROOM,3788047,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
TWIN CATH,3788048,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
EKG ER PRODUCTIVITY ONLY,3788060E,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
EKG ER,3788060E,CDM,730,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.05,70,,,percent of total billed charges,70% of total billed charges,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,373,
TRAY ER SUTURE,3788170,CDM,272,RC,,,Outpatient,,,147,88.2,,26.46,18,,,percent of total billed charges,pays at 18% of total charges,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.5,50,,,percent of total billed charges,pays at 50% of total billed charges,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,73.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,147,
TRAY ER SUTURE ANES,3788171,CDM,272,RC,,,Outpatient,,,194.5,116.7,,35.01,18,,,percent of total billed charges,pays at 18% of total charges,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.25,50,,,percent of total billed charges,pays at 50% of total billed charges,136.15,70,,,percent of total billed charges,70% of total billed charges,145.88,75,,,percent of total billed charges,75% of total billed charges,97.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,136.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,194.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.48,194.5,
TRAY ENDOTRACHEAL,3788180,CDM,272,RC,,,Outpatient,,,149,89.4,,26.82,18,,,percent of total billed charges,pays at 18% of total charges,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.5,50,,,percent of total billed charges,pays at 50% of total billed charges,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,74.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,149,
INJ TRIGGER POINT 1 OR 2,3788193,CDM,510,RC,20552,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,875,
NERVE BLOCK & LOCAL,3788194,CDM,450,RC,,,Outpatient,,,463.6,278.16,,83.45,18,,,percent of total billed charges,pays at 18% of total charges,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.8,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,347.7,75,,,percent of total billed charges,75% of total billed charges,231.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,370.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,354.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,324.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,463.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,417.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.65,463.6,
TRAY VAGINAL,3788195,CDM,272,RC,,,Outpatient,,,206,123.6,,37.08,18,,,percent of total billed charges,pays at 18% of total charges,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103,50,,,percent of total billed charges,pays at 50% of total billed charges,144.2,70,,,percent of total billed charges,70% of total billed charges,154.5,75,,,percent of total billed charges,75% of total billed charges,103,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,206,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,185.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,206,
TRAY ASPIRATION,3788196,CDM,272,RC,,,Outpatient,,,80.85,48.51,,14.55,18,,,percent of total billed charges,pays at 18% of total charges,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.43,50,,,percent of total billed charges,pays at 50% of total billed charges,56.6,70,,,percent of total billed charges,70% of total billed charges,60.64,75,,,percent of total billed charges,75% of total billed charges,40.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.67,80.85,
GREATER OCCIPITAL NERVE BLOCK,3788198,CDM,450,RC,,,Outpatient,,,565,339,,101.7,18,,,percent of total billed charges,pays at 18% of total charges,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,282.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,423.75,75,,,percent of total billed charges,75% of total billed charges,282.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,452,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,339,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,432.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,395.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,565,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,508.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.54,565,
INJ ANES AGNT OTHR PERPH NRV OR BRNCH,3788199,CDM,450,RC,,,Outpatient,,,1367,820.2,,246.06,18,,,percent of total billed charges,pays at 18% of total charges,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,683.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1025.25,75,,,percent of total billed charges,75% of total billed charges,683.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1093.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,820.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1045.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,956.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,820.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,956.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1367,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1230.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.21,1367,
TRAY SUTURE REMOVAL,3788201,CDM,272,RC,,,Outpatient,,,3.15,1.89,,0.57,18,,,percent of total billed charges,pays at 18% of total charges,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.58,50,,,percent of total billed charges,pays at 50% of total billed charges,2.21,70,,,percent of total billed charges,70% of total billed charges,2.36,75,,,percent of total billed charges,75% of total billed charges,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,3.15,
TRAY OB GYN,3788202,CDM,272,RC,,,Outpatient,,,134.1,80.46,,24.14,18,,,percent of total billed charges,pays at 18% of total charges,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.05,50,,,percent of total billed charges,pays at 50% of total billed charges,93.87,70,,,percent of total billed charges,70% of total billed charges,100.58,75,,,percent of total billed charges,75% of total billed charges,67.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,134.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.01,134.1,
THORACOTOMY TRAY,3788203,CDM,272,RC,,,Outpatient,,,381.15,228.69,,68.61,18,,,percent of total billed charges,pays at 18% of total charges,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,190.58,50,,,percent of total billed charges,pays at 50% of total billed charges,266.81,70,,,percent of total billed charges,70% of total billed charges,285.86,75,,,percent of total billed charges,75% of total billed charges,190.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,304.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,266.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,381.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,343.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.73,381.15,
TRAY CHEST TUBE INSERTN,3788231,CDM,272,RC,,,Outpatient,,,181.5,108.9,,32.67,18,,,percent of total billed charges,pays at 18% of total charges,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.75,50,,,percent of total billed charges,pays at 50% of total billed charges,127.05,70,,,percent of total billed charges,70% of total billed charges,136.13,75,,,percent of total billed charges,75% of total billed charges,90.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,145.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.44,181.5,
EAR WICKS,3788236,CDM,272,RC,,,Outpatient,,,11.5,6.9,,2.07,18,,,percent of total billed charges,pays at 18% of total charges,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.75,50,,,percent of total billed charges,pays at 50% of total billed charges,8.05,70,,,percent of total billed charges,70% of total billed charges,8.63,75,,,percent of total billed charges,75% of total billed charges,5.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.8,11.5,
WRIST IMMOBILIZER,3788240,CDM,271,RC,,,Outpatient,,,119.9,71.94,,21.58,18,,,percent of total billed charges,pays at 18% of total charges,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.95,50,,,percent of total billed charges,pays at 50% of total billed charges,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,59.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,119.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,119.9,
DEVICE PLASTIC COOLING DISP,3788266,CDM,272,RC,,,Outpatient,,,2080,1248,,374.4,18,,,percent of total billed charges,pays at 18% of total charges,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,374.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1040,50,,,percent of total billed charges,pays at 50% of total billed charges,1456,70,,,percent of total billed charges,70% of total billed charges,1560,75,,,percent of total billed charges,75% of total billed charges,1040,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1664,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1248,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1591.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,936,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1248,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,998.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1872,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,325.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.94,2080,
RPR INTERMEDIATE EXTREMITIES,3788271,CDM,450,RC,,,Outpatient,,,479,287.4,,86.22,18,,,percent of total billed charges,pays at 18% of total charges,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,359.25,75,,,percent of total billed charges,75% of total billed charges,239.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,383.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,366.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,479,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,431.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.06,479,
LENS MORGAN EYE IRRIGATN,3788285,CDM,272,RC,,,Outpatient,,,105.05,63.03,,18.91,18,,,percent of total billed charges,pays at 18% of total charges,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.53,50,,,percent of total billed charges,pays at 50% of total billed charges,73.54,70,,,percent of total billed charges,70% of total billed charges,78.79,75,,,percent of total billed charges,75% of total billed charges,52.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.46,105.05,
DERMABOND ADHESIVE,3788286,CDM,272,RC,,,Outpatient,,,83,49.8,,14.94,18,,,percent of total billed charges,pays at 18% of total charges,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41.5,50,,,percent of total billed charges,pays at 50% of total billed charges,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,41.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,83,
AMPUTATION FINGER THUMB,3788287,CDM,450,RC,26951,HCPCS,Outpatient,,,7410,4446,,9579.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7410,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5285.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,5557.5,75,,,percent of total billed charges,75% of total billed charges,4870.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5928,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9471.28,350,,,Fee Schedule,350% of CMS OPPS Rate,2760.2,103,,,Fee Schedule,103% of CMS OPPS Rate,5668.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3334.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5187,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4446,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5187,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3556.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6669,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7410,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,9579.52,
INC & DRNG VULVA/PERINEAL ABSCESS,3788288,CDM,450,RC,,,Outpatient,,,270.4,162.24,,48.67,18,,,percent of total billed charges,pays at 18% of total charges,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.2,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,202.8,75,,,percent of total billed charges,75% of total billed charges,135.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,216.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,270.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,243.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.37,270.4,
WRIST SUPPORTS ALL,3789001,CDM,274,RC,L3908,HCPCS,Outpatient,,,51.5,30.9,,222.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,113.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.05,350,,,Fee Schedule,350% of CMS OPPS Rate,64.13,102,,,Fee Schedule,102% of CMS OPPS Rate,51.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,,,,,Other,Not Separately reimbursable,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,51.5,230,,,Fee Schedule,230% of CMS OPPS Rate,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,100% of CMS OPPS Rate,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,8.07,222.56,
SLING ARM ALL,3789002,CDM,270,RC,,,Outpatient,,,42.9,25.74,,7.72,18,,,percent of total billed charges,pays at 18% of total charges,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.45,50,,,percent of total billed charges,pays at 50% of total billed charges,30.03,70,,,percent of total billed charges,70% of total billed charges,32.18,75,,,percent of total billed charges,75% of total billed charges,21.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.72,42.9,
STAPLER SKIN DISP,3789003,CDM,272,RC,,,Outpatient,,,89.5,53.7,,16.11,18,,,percent of total billed charges,pays at 18% of total charges,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.75,50,,,percent of total billed charges,pays at 50% of total billed charges,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,44.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,89.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,80.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,89.5,
UNNA BOOT STRAPPING,3789096,CDM,450,RC,,,Outpatient,,,205.75,123.45,,37.04,18,,,percent of total billed charges,pays at 18% of total charges,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.88,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,154.31,75,,,percent of total billed charges,75% of total billed charges,102.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,164.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,205.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,185.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.24,205.75,
EPISIOSTOMY OR VAGINAL REPAIR,3789300,CDM,450,RC,,,Outpatient,,,2505,1503,,450.9,18,,,percent of total billed charges,pays at 18% of total charges,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,450.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1252.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,1878.75,75,,,percent of total billed charges,75% of total billed charges,1252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2004,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1503,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1916.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1753.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1503,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1753.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1202.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2505,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2254.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,392.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.53,2505,
STRAPPING ANKLE AND/OR FOOT,3789540,CDM,450,RC,,,Outpatient,,,273.75,164.25,,49.28,18,,,percent of total billed charges,pays at 18% of total charges,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.88,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,205.31,75,,,percent of total billed charges,75% of total billed charges,136.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,273.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,246.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.9,273.75,
PUNCTURE ASPIRATION OF HYDROCELE,3789541,CDM,450,RC,,,Outpatient,,,1267,760.2,,228.06,18,,,percent of total billed charges,pays at 18% of total charges,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,228.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,950.25,75,,,percent of total billed charges,75% of total billed charges,633.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1013.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,760.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,969.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,886.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,760.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,886.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1267,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1140.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.54,1267,
ICP MONITOR INSERTION,3789542,CDM,450,RC,,,Outpatient,,,2669,1601.4,,480.42,18,,,percent of total billed charges,pays at 18% of total charges,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1334.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,2001.75,75,,,percent of total billed charges,75% of total billed charges,1334.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1601.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2041.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1201.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1868.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1601.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1868.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1281.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2669,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2402.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.23,2669,
APPLY LONG ARM SPLINT,3789543,CDM,450,RC,29105,HCPCS,Outpatient,,,341,204.6,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,276.11,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,53.43,469.08,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",3789544,CDM,450,RC,12011,HCPCS,Outpatient,,,357,214.2,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,357,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,267.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,273.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,357,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,581.14,
CLOSED TX CALCANEAL FX W MANIPULATION,3789545,CDM,450,RC,,,Outpatient,,,515,309,,92.7,18,,,percent of total billed charges,pays at 18% of total charges,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,257.5,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,386.25,75,,,percent of total billed charges,75% of total billed charges,257.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,393.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,515,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,463.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.7,515,
EXC SOFT TISS HAND/FNGR SQ 1.5CM />,3789546,CDM,450,RC,26111,HCPCS,Outpatient,,,3592,2155.2,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3592,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2336.23,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,2694,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2747.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1616.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2514.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2155.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2514.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1724.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3232.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3592,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,4825.85,
"CASIRIVI & IMDEVI INJ, POST ADM MONITOR",3789636,CDM,761,RC,M0243,HCPCS,Outpatient,,,630,378,,1449.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,409.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,315,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,737.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1433.42,350,,,Fee Schedule,350% of CMS OPPS Rate,417.74,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,941.96,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,1449.8,
POWDER STOMAHESIVE,3800001,CDM,272,RC,A4371,HCPCS,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
INPATIENT CONSULTATION,3808108,CDM,519,RC,99251,HCPCS,Outpatient,,,98.84,59.3,,17.79,18,,,percent of total billed charges,pays at 18% of total charges,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.13,75,,,percent of total billed charges,75% of total billed charges,49.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,79.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.49,98.84,
Outpatient visit of established patient not requiring a physician,3808110,CDM,519,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
Outpatient visit of established patient requiring a physician,3808111,CDM,519,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
DEBRIDEMENT OF NAIL 1 TO 5,3808112,CDM,519,RC,11720,HCPCS,Outpatient,,,126.45,75.87,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.84,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,96.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,56.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,60.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,113.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,184.98,
"Established patient office or other outpatient visit, typically 15 minutes",3808116,CDM,519,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
WOUND VAC <50SQCM,3808121,CDM,510,RC,97605,HCPCS,Outpatient,,,473,283.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,179.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.12,581.14,
WOUND VAC >50SQCM,3808122,CDM,510,RC,97606,HCPCS,Outpatient,,,865,519,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.75,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,692,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,661.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,389.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,519,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,328.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,415.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,778.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,135.55,1200.61,
MAGGOT THERAPY,3808211,CDM,510,RC,97602,HCPCS,Outpatient,,,202,121.2,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.5,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,154.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,90.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,96.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,181.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,31.65,581.14,
SETAPRESS,3808361,CDM,271,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
EAKIN SHIELD SMALL,3808362,CDM,272,RC,A4411,HCPCS,Outpatient,,,10.5,6.3,,1.89,18,,,percent of total billed charges,pays at 18% of total charges,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,70,,,percent of total billed charges,70% of total billed charges,7.88,75,,,percent of total billed charges,75% of total billed charges,5.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.65,10.5,
EAKIN SHIELD,3808363,CDM,272,RC,A4411,HCPCS,Outpatient,,,49,29.4,,8.82,18,,,percent of total billed charges,pays at 18% of total charges,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,70,,,percent of total billed charges,70% of total billed charges,36.75,75,,,percent of total billed charges,75% of total billed charges,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,49,
SKIN BARRIER,3808886,CDM,272,RC,A4406,HCPCS,Outpatient,,,43,25.8,,7.74,18,,,percent of total billed charges,pays at 18% of total charges,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,21.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.74,43,
INITIAL OSTOMY SUPPLY,3809004,CDM,272,RC,,,Outpatient,,,126,75.6,,22.68,18,,,percent of total billed charges,pays at 18% of total charges,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,50,,,percent of total billed charges,pays at 50% of total billed charges,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,126,
BOOT HEEL,3809009,CDM,270,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
DUODERM PASTE,3809017,CDM,272,RC,,,Outpatient,,,51.5,30.9,,9.27,18,,,percent of total billed charges,pays at 18% of total charges,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.75,50,,,percent of total billed charges,pays at 50% of total billed charges,36.05,70,,,percent of total billed charges,70% of total billed charges,38.63,75,,,percent of total billed charges,75% of total billed charges,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.07,51.5,
COLOSTOMY IRRIGATION,3809022,CDM,272,RC,A4397,HCPCS,Outpatient,,,252,151.2,,45.36,18,,,percent of total billed charges,pays at 18% of total charges,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,252,
DRSG MEPITEL,3809026,CDM,272,RC,,,Outpatient,,,10,6,,1.8,18,,,percent of total billed charges,pays at 18% of total charges,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5,50,,,percent of total billed charges,pays at 50% of total billed charges,7,70,,,percent of total billed charges,70% of total billed charges,7.5,75,,,percent of total billed charges,75% of total billed charges,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,10,
DRSG CA+ ALG AG,3809028,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
NUGAUZE ALL SIZES,3809030,CDM,272,RC,,,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.75,50,,,percent of total billed charges,pays at 50% of total billed charges,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
OSTOMY BELT,3809032,CDM,272,RC,A4367,HCPCS,Outpatient,,,10,6,,1.8,18,,,percent of total billed charges,pays at 18% of total charges,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7,70,,,percent of total billed charges,70% of total billed charges,7.5,75,,,percent of total billed charges,75% of total billed charges,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,10,
CONE IRRIGATION KIT,3809034,CDM,272,RC,A4398,HCPCS,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,70,,,percent of total billed charges,70% of total billed charges,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
TUBULAR NET,3809042,CDM,272,RC,,,Outpatient,,,5,3,,0.9,18,,,percent of total billed charges,pays at 18% of total charges,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3.5,70,,,percent of total billed charges,70% of total billed charges,3.75,75,,,percent of total billed charges,75% of total billed charges,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,5,
SAF-GEL W/ALGINATE,3809044,CDM,272,RC,,,Outpatient,,,15,9,,2.7,18,,,percent of total billed charges,pays at 18% of total charges,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10.5,70,,,percent of total billed charges,70% of total billed charges,11.25,75,,,percent of total billed charges,75% of total billed charges,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,15,
MATISOL SX ADH.2/3CC,3809046,CDM,271,RC,,,Outpatient,,,5,3,,0.9,18,,,percent of total billed charges,pays at 18% of total charges,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3.5,70,,,percent of total billed charges,70% of total billed charges,3.75,75,,,percent of total billed charges,75% of total billed charges,2.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,5,
DRSG SACRUM ADH FOAM,3809048,CDM,272,RC,,,Outpatient,,,24,14.4,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12,50,,,percent of total billed charges,pays at 50% of total billed charges,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,24,
DRSG FOAM NON ADH 4X4,3809052,CDM,272,RC,,,Outpatient,,,10,6,,1.8,18,,,percent of total billed charges,pays at 18% of total charges,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5,50,,,percent of total billed charges,pays at 50% of total billed charges,7,70,,,percent of total billed charges,70% of total billed charges,7.5,75,,,percent of total billed charges,75% of total billed charges,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,10,
BUTTON PLACEMENT GI,3809054,CDM,761,RC,43760,HCPCS,Outpatient,,,960,576,,172.8,18,,,percent of total billed charges,pays at 18% of total charges,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,467.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,720,75,,,percent of total billed charges,75% of total billed charges,480,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,768,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,734.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,165.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,960,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,864,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.43,960,
SLEEVE OSTOMY IRRIGATION,3809056,CDM,272,RC,A4397,HCPCS,Outpatient,,,12.5,7.5,,2.25,18,,,percent of total billed charges,pays at 18% of total charges,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.75,70,,,percent of total billed charges,70% of total billed charges,9.38,75,,,percent of total billed charges,75% of total billed charges,6.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.96,12.5,
DRSG FOAM AG NON ADHESIVE,3809058,CDM,272,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
UROSTOMY POUCH,3809060,CDM,272,RC,A4428,HCPCS,Outpatient,,,10,6,,1.8,18,,,percent of total billed charges,pays at 18% of total charges,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7,70,,,percent of total billed charges,70% of total billed charges,7.5,75,,,percent of total billed charges,75% of total billed charges,5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.57,10,
DRSG ODOR ABSORBANT,3809068,CDM,272,RC,,,Outpatient,,,15,9,,2.7,18,,,percent of total billed charges,pays at 18% of total charges,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10.5,70,,,percent of total billed charges,70% of total billed charges,11.25,75,,,percent of total billed charges,75% of total billed charges,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,15,
SILVASORB AG,3809074,CDM,272,RC,,,Outpatient,,,36,21.6,,6.48,18,,,percent of total billed charges,pays at 18% of total charges,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18,50,,,percent of total billed charges,pays at 50% of total billed charges,25.2,70,,,percent of total billed charges,70% of total billed charges,27,75,,,percent of total billed charges,75% of total billed charges,18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.64,36,
MATISOL SX ADH. 15ML PUMP,3809076,CDM,271,RC,,,Outpatient,,,22.5,13.5,,4.05,18,,,percent of total billed charges,pays at 18% of total charges,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,50,,,percent of total billed charges,pays at 50% of total billed charges,15.75,70,,,percent of total billed charges,70% of total billed charges,16.88,75,,,percent of total billed charges,75% of total billed charges,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,22.5,
POUCH DRAIN HIGH OUTPUT,3809078,CDM,272,RC,A4412,HCPCS,Outpatient,,,7.5,4.5,,1.35,18,,,percent of total billed charges,pays at 18% of total charges,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.25,70,,,percent of total billed charges,70% of total billed charges,5.63,75,,,percent of total billed charges,75% of total billed charges,3.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.18,7.5,
DRSG DUODERM CGF 6X6,3809080,CDM,272,RC,,,Outpatient,,,27.5,16.5,,4.95,18,,,percent of total billed charges,pays at 18% of total charges,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.75,50,,,percent of total billed charges,pays at 50% of total billed charges,19.25,70,,,percent of total billed charges,70% of total billed charges,20.63,75,,,percent of total billed charges,75% of total billed charges,13.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,27.5,
POUCH WOUND COLLECTION,3809081,CDM,272,RC,,,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
CONTACT LAYER AG-4X4,3809094,CDM,272,RC,,,Outpatient,,,22.5,13.5,,4.05,18,,,percent of total billed charges,pays at 18% of total charges,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.25,50,,,percent of total billed charges,pays at 50% of total billed charges,15.75,70,,,percent of total billed charges,70% of total billed charges,16.88,75,,,percent of total billed charges,75% of total billed charges,11.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.53,22.5,
UNNA BOOT STRAPPING,3809096,CDM,510,RC,29580,HCPCS,Outpatient,,,188,112.8,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,71.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,29.46,469.08,
APPLICATION OF MULTI-LAYER COMPRESSION,3809098,CDM,510,RC,29581,HCPCS,Outpatient,,,137.33,82.4,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,105.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,61.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,52.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,96.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,65.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,123.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,21.52,469.08,
NONSELECTIVE WOUND DEBRID,3809190,CDM,510,RC,97602,HCPCS,Outpatient,,,153,91.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,153,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,153,103,,,Fee Schedule,103% of CMS OPPS Rate,117.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,58.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,107.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,73.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,153,100,,,Fee Schedule,100% of CMS OPPS Rate,137.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,23.98,581.14,
OUTPATIENT VISIT NEW BRIEF,3809211,CDM,510,RC,99201,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.27,123,
"New patient office or other outpatient visit, typically 10 minutes",3809212,CDM,510,RC,99202,HCPCS,Outpatient,,,152,91.2,,27.36,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,152,
"New patient office or other outpatient visit, typically 30 min",3809213,CDM,510,RC,99203,HCPCS,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,228,
DIALYSIS-RENAL,3819002,CDM,801,RC,G0257,HCPCS,Outpatient,,,1817.64,1090.58,,2029.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,573.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,573.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1219.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1272.35,70,,,percent of total billed charges,70% of total billed charges,1363.23,75,,,percent of total billed charges,75% of total billed charges,1031.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1454.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2006.22,350,,,Fee Schedule,350% of CMS OPPS Rate,584.66,103,,,Fee Schedule,103% of CMS OPPS Rate,1390.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,817.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1272.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1090.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,690.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1272.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.36,100,,,Fee Schedule,100% of CMS OPPS Rate,872.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1635.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,100,,,Fee Schedule,100% of CMS OPPS Rate,573.2,2029.14,
DISCOGRAM,3825025,CDM,360,RC,,,Outpatient,,,3775,2265,,679.5,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,679.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1887.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2642.5,70,,,percent of total billed charges,70% of total billed charges,2831.25,75,,,percent of total billed charges,75% of total billed charges,1887.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3020,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2265,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2887.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1698.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2642.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2265,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1434.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2642.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1812,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3775,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3397.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,679.5,3775,
RHINOPLASTY,3828035,CDM,360,RC,30400,HCPCS,Outpatient,,,5010,3006,,17184.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4854.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4854.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6723.23,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3507,70,,,percent of total billed charges,70% of total billed charges,3757.5,75,,,percent of total billed charges,75% of total billed charges,8737.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16990.02,350,,,Fee Schedule,350% of CMS OPPS Rate,4951.37,103,,,Fee Schedule,103% of CMS OPPS Rate,3832.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2254.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3507,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3006,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3507,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,11164.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2404.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4509,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4854.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,17184.2,
BLEPH UPPER EYELIDS BILAT,3829381,CDM,360,RC,15822,HCPCS,Outpatient,,,5010,3006,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3197.87,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3507,70,,,percent of total billed charges,70% of total billed charges,3757.5,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,3832.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2254.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3507,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3006,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3507,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2404.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,4509,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,5554.18,
BLOCK NERVE,3829382,CDM,360,RC,,,Outpatient,,,2220,1332,,399.6,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,399.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1110,50,,,percent of total billed charges,pays at 50% of total billed charges,1554,70,,,percent of total billed charges,70% of total billed charges,1665,75,,,percent of total billed charges,75% of total billed charges,1110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1776,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1332,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1698.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,999,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1554,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1332,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1554,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2220,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1998,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.6,2220,
DESTRUCTION OR ABLATION NERVE,3829383,CDM,360,RC,,,Outpatient,,,3415,2049,,614.7,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,614.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1707.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2390.5,70,,,percent of total billed charges,70% of total billed charges,2561.25,75,,,percent of total billed charges,75% of total billed charges,1707.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2732,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2049,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2612.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2390.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2049,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1297.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2390.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1639.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3415,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3073.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.7,3415,
INJECTION BOTOX,3829385,CDM,360,RC,,,Outpatient,,,3400,2040,,612,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,612,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1700,50,,,percent of total billed charges,pays at 50% of total billed charges,2380,70,,,percent of total billed charges,70% of total billed charges,2550,75,,,percent of total billed charges,75% of total billed charges,1700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2040,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2601,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2040,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1292,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1632,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3060,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612,3400,
INJECTION W IMAGING,3829514,CDM,360,RC,,,Outpatient,,,1735,1041,,312.3,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,312.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,867.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1214.5,70,,,percent of total billed charges,70% of total billed charges,1301.25,75,,,percent of total billed charges,75% of total billed charges,867.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1388,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1041,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1327.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1214.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1041,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,659.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1214.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,832.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1735,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1561.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.3,1735,
Immunization administration by a medical assistant or nurse,3840001,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ADMIN PNEUMONIA VACCINE,3840002,CDM,771,RC,G0009,HCPCS,Outpatient,,,45.5,27.3,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.85,70,,,percent of total billed charges,70% of total billed charges,34.13,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,34.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.43,100,,,Case rate,pays based on per visit rate,40.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,136.34,
Immunization administration by a medical assistant or nurse,3840004,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,3840005,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Surgical procedures on the kidney to break up and remove kidney stones,3851004,CDM,790,RC,50590,HCPCS,Outpatient,,,16657.47,9994.48,,10314.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16657.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2913.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2913.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7102.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,12493.1,75,,,percent of total billed charges,75% of total billed charges,12493.1,75,,,percent of total billed charges,75% of total billed charges,5244.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,13325.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10198.2,350,,,Fee Schedule,350% of CMS OPPS Rate,2972.04,103,,,Fee Schedule,103% of CMS OPPS Rate,12742.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7495.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11660.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9994.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11660.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11660.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6701.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2575,100,,,Case rate,pays based on per visit rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,14991.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16657.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2575,16657.47,
URETEROSCOPY,3851010,CDM,490,RC,52351,HCPCS,Outpatient,,,4424.18,2654.51,,10314.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,550.32,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping Rate,2913.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2913.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3249.88,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3096.93,70,,,percent of total billed charges,70% of total billed charges,3318.14,75,,,percent of total billed charges,75% of total billed charges,5244.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3539.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10198.2,350,,,Fee Schedule,350% of CMS OPPS Rate,2972.04,103,,,Fee Schedule,103% of CMS OPPS Rate,3384.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3096.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2654.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3096.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6701.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2123.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3981.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,550.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,550.32,10314.75,
DIABETES ED - 30 MIN OP,3921010,CDM,942,RC,G0108,HCPCS,Outpatient,,,83,49.8,,184.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,94.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.81,350,,,Fee Schedule,350% of CMS OPPS Rate,53.27,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,120.13,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,191,
DIABETES ED - 15 MIN INPT,3921025,CDM,942,RC,G0108,HCPCS,Outpatient,,,83,49.8,,184.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,94.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.81,350,,,Fee Schedule,350% of CMS OPPS Rate,53.27,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,120.13,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,191,
DIABETES ED - 30 MIN INPT,3921030,CDM,942,RC,G0108,HCPCS,Outpatient,,,109.8,65.88,,184.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.86,70,,,percent of total billed charges,70% of total billed charges,82.35,75,,,percent of total billed charges,75% of total billed charges,94.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,87.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.81,350,,,Fee Schedule,350% of CMS OPPS Rate,53.27,102,,,Fee Schedule,102% of CMS OPPS Rate,84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,76.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,120.13,230,,,Fee Schedule,230% of CMS OPPS Rate,52.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,98.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,191,
DIABETES ED - 45 MIN INPT,3921035,CDM,942,RC,G0108,HCPCS,Outpatient,,,208.8,125.28,,184.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,146.16,70,,,percent of total billed charges,70% of total billed charges,156.6,75,,,percent of total billed charges,75% of total billed charges,94.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,167.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.81,350,,,Fee Schedule,350% of CMS OPPS Rate,53.27,102,,,Fee Schedule,102% of CMS OPPS Rate,159.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,93.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,146.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,146.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,120.13,230,,,Fee Schedule,230% of CMS OPPS Rate,100.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,187.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,191,
DIABETES ED - 1 HR  INPT,3921040,CDM,942,RC,G0108,HCPCS,Outpatient,,,217.35,130.41,,184.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.15,70,,,percent of total billed charges,70% of total billed charges,163.01,75,,,percent of total billed charges,75% of total billed charges,94.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.81,350,,,Fee Schedule,350% of CMS OPPS Rate,53.27,102,,,Fee Schedule,102% of CMS OPPS Rate,166.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,97.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,152.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,152.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,120.13,230,,,Fee Schedule,230% of CMS OPPS Rate,104.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,195.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,52.23,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,195.62,
DIABETES ED OP/GRP 30 MN,3921065,CDM,942,RC,G0109,HCPCS,Outpatient,,,43,25.8,,52.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,26.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.77,350,,,Fee Schedule,350% of CMS OPPS Rate,15.09,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,34.02,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,10.53,191,
Automated urinalysis test,4021002,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
HCT HEMATOCRIT BLOOD,4021014,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
Manual urinalysis test with examination with or without using microscope,4021015,CDM,307,RC,81001,HCPCS,Outpatient,,,164.25,98.55,,11.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.98,70,,,percent of total billed charges,70% of total billed charges,123.19,75,,,percent of total billed charges,75% of total billed charges,5.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.09,350,,,Fee Schedule,350% of CMS OPPS Rate,3.23,102,,,Fee Schedule,102% of CMS OPPS Rate,125.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.53,100,,,Fee Schedule,100% of UHC Fee Schedule,114.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,7.29,230,,,Fee Schedule,230% of CMS OPPS Rate,78.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,147.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,147.83,
Blood test to measure levels of hemoglobin,4021018,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
Urine pregnancy test,4021025,CDM,300,RC,81025,HCPCS,Outpatient,,,57.08,34.25,,30.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.96,70,,,percent of total billed charges,70% of total billed charges,42.81,75,,,percent of total billed charges,75% of total billed charges,15.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,45.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.13,350,,,Fee Schedule,350% of CMS OPPS Rate,8.78,102,,,Fee Schedule,102% of CMS OPPS Rate,43.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,25.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,100,,,Fee Schedule,100% of UHC Fee Schedule,39.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,230,,,Fee Schedule,230% of CMS OPPS Rate,27.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,51.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,51.37,
"Complete blood cell count, with differential white blood cells, automated",4021026,CDM,305,RC,85025,HCPCS,Outpatient,,,180.45,108.27,,27.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges,135.34,75,,,percent of total billed charges,75% of total billed charges,13.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,144.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.19,350,,,Fee Schedule,350% of CMS OPPS Rate,7.92,102,,,Fee Schedule,102% of CMS OPPS Rate,138.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,81.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,100% of UHC Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17.87,230,,,Fee Schedule,230% of CMS OPPS Rate,86.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,162.41,
"Complete blood count, automated",4021027,CDM,305,RC,85027,HCPCS,Outpatient,,,121.95,73.17,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.18,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,109.76,
ANA(REFLEX TITER),4021038,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
Blood test to determine autoimmune disorders,4021039,CDM,302,RC,86039,HCPCS,Outpatient,,,233.2,139.92,,39.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,163.24,70,,,percent of total billed charges,70% of total billed charges,174.9,75,,,percent of total billed charges,75% of total billed charges,20.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.06,350,,,Fee Schedule,350% of CMS OPPS Rate,11.38,102,,,Fee Schedule,102% of CMS OPPS Rate,178.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,100% of UHC Fee Schedule,163.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,25.66,230,,,Fee Schedule,230% of CMS OPPS Rate,111.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,209.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,209.88,
RETICULOCYTE  AUTOMATED,4021044,CDM,305,RC,85045,HCPCS,Outpatient,,,38.7,23.22,,14.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,27.09,70,,,percent of total billed charges,70% of total billed charges,29.03,75,,,percent of total billed charges,75% of total billed charges,7.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,30.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,350,,,Fee Schedule,350% of CMS OPPS Rate,4.06,102,,,Fee Schedule,102% of CMS OPPS Rate,29.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,17.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,4.44,100,,,Fee Schedule,100% of UHC Fee Schedule,27.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,9.17,230,,,Fee Schedule,230% of CMS OPPS Rate,18.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,34.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,34.83,
WBC WHITE BLD CELL COUNT BLD,4021048,CDM,305,RC,85048,HCPCS,Outpatient,,,116.6,69.96,,8.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,4.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,350,,,Fee Schedule,350% of CMS OPPS Rate,2.59,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5.84,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,104.94,
ANTI-DS DNA,4021102,CDM,302,RC,86225,HCPCS,Outpatient,,,47.3,28.38,,48.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges,35.48,75,,,percent of total billed charges,75% of total billed charges,24.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,350,,,Fee Schedule,350% of CMS OPPS Rate,14.01,102,,,Fee Schedule,102% of CMS OPPS Rate,36.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.27,100,,,Fee Schedule,100% of UHC Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,48.63,
Blood test to measure levels of hemoglobin,4021118,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
MONONUCLEOSIS SCRN BLD,4021150,CDM,302,RC,86308,HCPCS,Outpatient,,,115.5,69.3,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,103.95,
EXTRACTABLE N AG IGG ABS,4021154,CDM,302,RC,86235,HCPCS,Outpatient,,,33.5,20.1,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.45,70,,,percent of total billed charges,70% of total billed charges,25.13,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,25.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,23.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,33.5,230,,,Fee Schedule,230% of CMS OPPS Rate,16.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,30.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
RA(REFLEX TITER),4021160,CDM,302,RC,86430,HCPCS,Outpatient,,,94.5,56.7,,21.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,11.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.49,350,,,Fee Schedule,350% of CMS OPPS Rate,6.26,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,85.05,
RA QUANTITATIVE,4021161,CDM,302,RC,86431,HCPCS,Outpatient,,,88,52.8,,20.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,10.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.84,350,,,Fee Schedule,350% of CMS OPPS Rate,5.78,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.04,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,79.2,
SM(SMITH) IGG ABS,4021235,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
Blood test to if peptic ulcers are caused by a certain bacterium,4021248,CDM,302,RC,86677,HCPCS,Outpatient,,,55.55,33.33,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,41.66,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,42.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,100% of UHC Fee Schedule,38.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,26.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,50,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,59.64,
FLORESCENT CHEM ABS,4021256,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
PA SCREEN EA AB,4021403,CDM,302,RC,86403,HCPCS,Outpatient,,,74.7,44.82,,40.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges,56.03,75,,,percent of total billed charges,75% of total billed charges,20.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.38,350,,,Fee Schedule,350% of CMS OPPS Rate,11.77,102,,,Fee Schedule,102% of CMS OPPS Rate,57.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,33.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.32,100,,,Fee Schedule,100% of UHC Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,26.54,230,,,Fee Schedule,230% of CMS OPPS Rate,35.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.32,67.23,
PA TITER EA AB,4021406,CDM,302,RC,86406,HCPCS,Outpatient,,,74.7,44.82,,37.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges,56.03,75,,,percent of total billed charges,75% of total billed charges,19.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.24,350,,,Fee Schedule,350% of CMS OPPS Rate,10.85,102,,,Fee Schedule,102% of CMS OPPS Rate,57.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,33.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of UHC Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.47,230,,,Fee Schedule,230% of CMS OPPS Rate,35.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,67.23,
Blood test to assess for pregnancy,4021500,CDM,301,RC,84703,HCPCS,Outpatient,,,221.65,132.99,,26.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.16,70,,,percent of total billed charges,70% of total billed charges,166.24,75,,,percent of total billed charges,75% of total billed charges,13.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.32,350,,,Fee Schedule,350% of CMS OPPS Rate,7.67,102,,,Fee Schedule,102% of CMS OPPS Rate,169.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,99.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of UHC Fee Schedule,155.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,17.29,230,,,Fee Schedule,230% of CMS OPPS Rate,106.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,199.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,199.49,
PLATELET COUNT AUTOMATED,4021580,CDM,305,RC,85049,HCPCS,Outpatient,,,54.9,32.94,,15.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.28,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,8.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.68,350,,,Fee Schedule,350% of CMS OPPS Rate,4.56,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.98,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,49.41,
Blood test to screen for syphilis,4021592,CDM,302,RC,86592,HCPCS,Outpatient,,,80.55,48.33,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,61.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,38.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,72.5,
RPR TITER,4021593,CDM,302,RC,86593,HCPCS,Outpatient,,,80.55,48.33,,15.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,7.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.4,350,,,Fee Schedule,350% of CMS OPPS Rate,4.48,102,,,Fee Schedule,102% of CMS OPPS Rate,61.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of UHC Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,230,,,Fee Schedule,230% of CMS OPPS Rate,38.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,72.5,
"Blood test, clotting time",4021610,CDM,305,RC,85610,HCPCS,Outpatient,,,67.95,40.77,,15.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.57,70,,,percent of total billed charges,70% of total billed charges,50.96,75,,,percent of total billed charges,75% of total billed charges,7.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.01,350,,,Fee Schedule,350% of CMS OPPS Rate,4.37,102,,,Fee Schedule,102% of CMS OPPS Rate,51.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,30.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,47.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,9.86,230,,,Fee Schedule,230% of CMS OPPS Rate,32.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,61.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,61.16,
SED RATE ESR BLD,4021651,CDM,305,RC,85651,HCPCS,Outpatient,,,80.85,48.51,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.6,70,,,percent of total billed charges,70% of total billed charges,60.64,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,61.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,36.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of UHC Fee Schedule,56.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,38.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,72.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,72.77,
HCT HEMATOCRIT BLOOD,4021700,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
Blood test to measure levels of hemoglobin,4021700,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
Coagulation assessment blood test,4021730,CDM,305,RC,85730,HCPCS,Outpatient,,,152.1,91.26,,21.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,10.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.03,350,,,Fee Schedule,350% of CMS OPPS Rate,6.13,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,136.89,
Automated urinalysis test,4022002,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
Manual urinalysis test with examination with or without using microscope,4022015,CDM,307,RC,81001,HCPCS,Outpatient,,,164.25,98.55,,11.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.98,70,,,percent of total billed charges,70% of total billed charges,123.19,75,,,percent of total billed charges,75% of total billed charges,5.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.09,350,,,Fee Schedule,350% of CMS OPPS Rate,3.23,102,,,Fee Schedule,102% of CMS OPPS Rate,125.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.53,100,,,Fee Schedule,100% of UHC Fee Schedule,114.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,7.29,230,,,Fee Schedule,230% of CMS OPPS Rate,78.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,147.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3.17,147.83,
FETAL FEBRONECTIN,4022731,CDM,301,RC,82731,HCPCS,Outpatient,,,434.7,260.82,,228.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,162.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,304.29,70,,,percent of total billed charges,70% of total billed charges,326.03,75,,,percent of total billed charges,75% of total billed charges,115.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,347.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.43,350,,,Fee Schedule,350% of CMS OPPS Rate,65.69,102,,,Fee Schedule,102% of CMS OPPS Rate,332.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,195.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,71.57,100,,,Fee Schedule,100% of UHC Fee Schedule,304.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,148.14,230,,,Fee Schedule,230% of CMS OPPS Rate,208.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,391.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.81,391.23,
SICKLE CELL SCREEN BLD,4023053,CDM,305,RC,85660,HCPCS,Outpatient,,,61.65,36.99,,19.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.16,70,,,percent of total billed charges,70% of total billed charges,46.24,75,,,percent of total billed charges,75% of total billed charges,9.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.28,350,,,Fee Schedule,350% of CMS OPPS Rate,5.62,102,,,Fee Schedule,102% of CMS OPPS Rate,47.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,27.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.12,100,,,Fee Schedule,100% of UHC Fee Schedule,43.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,12.67,230,,,Fee Schedule,230% of CMS OPPS Rate,29.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,55.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.51,55.49,
Blood test to assess for pregnancy,4023500,CDM,301,RC,84703,HCPCS,Outpatient,,,221.65,132.99,,26.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.16,70,,,percent of total billed charges,70% of total billed charges,166.24,75,,,percent of total billed charges,75% of total billed charges,13.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.32,350,,,Fee Schedule,350% of CMS OPPS Rate,7.67,102,,,Fee Schedule,102% of CMS OPPS Rate,169.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,99.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of UHC Fee Schedule,155.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,17.29,230,,,Fee Schedule,230% of CMS OPPS Rate,106.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,199.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,199.49,
RA QUANTITATIVE,4024161,CDM,302,RC,86431,HCPCS,Outpatient,,,88,52.8,,20.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,10.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.84,350,,,Fee Schedule,350% of CMS OPPS Rate,5.78,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.04,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,79.2,
CRYSTAL ID BY LIGHT MICROSCOPY,4024206,CDM,309,RC,89060,HCPCS,Outpatient,,,85.05,51.03,,25.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.54,70,,,percent of total billed charges,70% of total billed charges,63.79,75,,,percent of total billed charges,75% of total billed charges,13.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.65,350,,,Fee Schedule,350% of CMS OPPS Rate,7.47,102,,,Fee Schedule,102% of CMS OPPS Rate,65.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,38.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.95,100,,,Fee Schedule,100% of UHC Fee Schedule,59.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,230,,,Fee Schedule,230% of CMS OPPS Rate,40.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,76.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7.33,76.55,
HCT HEMATOCRIT BLD,4025014,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
Blood test to measure levels of hemoglobin,4025018,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
"Complete blood cell count, with differential white blood cells, automated",4025026,CDM,305,RC,85025,HCPCS,Outpatient,,,180.45,108.27,,27.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges,135.34,75,,,percent of total billed charges,75% of total billed charges,13.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,144.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.19,350,,,Fee Schedule,350% of CMS OPPS Rate,7.92,102,,,Fee Schedule,102% of CMS OPPS Rate,138.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,81.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.63,100,,,Fee Schedule,100% of UHC Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17.87,230,,,Fee Schedule,230% of CMS OPPS Rate,86.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,162.41,
"Complete blood count, automated",4025027,CDM,305,RC,85027,HCPCS,Outpatient,,,121.95,73.17,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.18,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,109.76,
Blood test to assess for infection,4025030,CDM,305,RC,85007,HCPCS,Outpatient,,,69.75,41.85,,13.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,6.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.3,350,,,Fee Schedule,350% of CMS OPPS Rate,3.87,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.82,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,62.78,
RETICULOCYTE  AUTOMATED,4025044,CDM,305,RC,85045,HCPCS,Outpatient,,,38.7,23.22,,14.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,27.09,70,,,percent of total billed charges,70% of total billed charges,29.03,75,,,percent of total billed charges,75% of total billed charges,7.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,30.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.96,350,,,Fee Schedule,350% of CMS OPPS Rate,4.06,102,,,Fee Schedule,102% of CMS OPPS Rate,29.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,17.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,4.44,100,,,Fee Schedule,100% of UHC Fee Schedule,27.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,9.17,230,,,Fee Schedule,230% of CMS OPPS Rate,18.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,34.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3.99,34.83,
WBC WHITE BLD CELL COUNT BLD,4025048,CDM,305,RC,85048,HCPCS,Outpatient,,,116.6,69.96,,8.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,4.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,350,,,Fee Schedule,350% of CMS OPPS Rate,2.59,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5.84,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,104.94,
RETICULATED PLATELET ASSAY,4025055,CDM,305,RC,85055,HCPCS,Outpatient,,,60,36,,126.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,64.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.09,350,,,Fee Schedule,350% of CMS OPPS Rate,36.45,102,,,Fee Schedule,102% of CMS OPPS Rate,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of UHC Fee Schedule,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,60,230,,,Fee Schedule,230% of CMS OPPS Rate,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.74,100,,,Fee Schedule,100% of CMS OPPS Rate,27,126.51,
BLOOD SMEAR PERIPHERAL INTERP,4025060,CDM,900,RC,85060,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,278,
BONE MARROW ASPIRATION,4025095,CDM,360,RC,38220,HCPCS,Outpatient,,,360,216,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,360,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2088.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,252,70,,,percent of total billed charges,70% of total billed charges,270,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,360,103,,,Fee Schedule,103% of CMS OPPS Rate,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,360,100,,,Fee Schedule,100% of CMS OPPS Rate,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,162,4825.85,
BONE MARROW BIOPSY,4025096,CDM,360,RC,38221,HCPCS,Outpatient,,,600,360,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,600,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,420,70,,,percent of total billed charges,70% of total billed charges,450,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,600,103,,,Fee Schedule,103% of CMS OPPS Rate,459,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,270,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,420,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,288,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,600,100,,,Fee Schedule,100% of CMS OPPS Rate,540,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,270,4825.85,
BM ASP WITH BM BX,4025097,CDM,761,RC,38222,HCPCS,Outpatient,,,217,130.2,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,217,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,217,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1236.82,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,162.75,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,217,103,,,Fee Schedule,103% of CMS OPPS Rate,166.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,97.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,104.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,217,100,,,Fee Schedule,100% of CMS OPPS Rate,195.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,8313.44,
"FACTOR IX ASSAY, PLASMA",4025240,CDM,305,RC,85250,HCPCS,Outpatient,,,292.95,175.77,,67.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.07,70,,,percent of total billed charges,70% of total billed charges,219.71,75,,,percent of total billed charges,75% of total billed charges,34.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.64,350,,,Fee Schedule,350% of CMS OPPS Rate,19.42,102,,,Fee Schedule,102% of CMS OPPS Rate,224.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,131.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,21.16,100,,,Fee Schedule,100% of UHC Fee Schedule,205.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,43.79,230,,,Fee Schedule,230% of CMS OPPS Rate,140.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,263.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,263.66,
"FACTOR VIII ASSAY, PLASMA",4025250,CDM,305,RC,85240,HCPCS,Outpatient,,,304.2,182.52,,63.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.94,70,,,percent of total billed charges,70% of total billed charges,228.15,75,,,percent of total billed charges,75% of total billed charges,32.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,243.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.64,350,,,Fee Schedule,350% of CMS OPPS Rate,18.25,102,,,Fee Schedule,102% of CMS OPPS Rate,232.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,100,,,Fee Schedule,100% of UHC Fee Schedule,212.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.17,230,,,Fee Schedule,230% of CMS OPPS Rate,146.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,273.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,273.78,
COAGULATION TIME ACTIVATED,4025347,CDM,305,RC,85347,HCPCS,Outpatient,,,68.72,41.23,,15.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.1,70,,,percent of total billed charges,70% of total billed charges,51.54,75,,,percent of total billed charges,75% of total billed charges,7.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.98,350,,,Fee Schedule,350% of CMS OPPS Rate,4.36,102,,,Fee Schedule,102% of CMS OPPS Rate,52.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,30.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of UHC Fee Schedule,48.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,9.84,230,,,Fee Schedule,230% of CMS OPPS Rate,32.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.5,61.85,
FDP FIBRIN DEGRAD PROD SERUM,4025362,CDM,305,RC,85362,HCPCS,Outpatient,,,176.85,106.11,,24.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.8,70,,,percent of total billed charges,70% of total billed charges,132.64,75,,,percent of total billed charges,75% of total billed charges,12.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,141.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.11,350,,,Fee Schedule,350% of CMS OPPS Rate,7.02,102,,,Fee Schedule,102% of CMS OPPS Rate,135.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,79.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,7.66,100,,,Fee Schedule,100% of UHC Fee Schedule,123.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,230,,,Fee Schedule,230% of CMS OPPS Rate,84.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,159.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.69,159.17,
FIBRINOGEN PLASMA,4025371,CDM,305,RC,85384,HCPCS,Outpatient,,,73.8,44.28,,34.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,17.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.02,350,,,Fee Schedule,350% of CMS OPPS Rate,9.91,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,66.42,
COAGULOPATHY SCREEN INTERP REPORT,4025390,CDM,305,RC,85390,HCPCS,Outpatient,,,77.44,46.46,,54.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.21,70,,,percent of total billed charges,70% of total billed charges,58.08,75,,,percent of total billed charges,75% of total billed charges,27.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.18,350,,,Fee Schedule,350% of CMS OPPS Rate,15.78,102,,,Fee Schedule,102% of CMS OPPS Rate,59.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,34.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of UHC Fee Schedule,54.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,35.6,230,,,Fee Schedule,230% of CMS OPPS Rate,37.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,69.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.67,69.7,
PLT AGGRN -ARISTOCETIN EA (PLAVIX),4025570,CDM,305,RC,85576,HCPCS,Outpatient,,,102.15,61.29,,88.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,44.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.18,350,,,Fee Schedule,350% of CMS OPPS Rate,25.4,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,23.87,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,57.29,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.35,91.94,
PLATELET COUNT AUTOMATED,4025580,CDM,305,RC,85049,HCPCS,Outpatient,,,54.9,32.94,,15.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.28,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,8.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.68,350,,,Fee Schedule,350% of CMS OPPS Rate,4.56,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.98,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,100,,,Fee Schedule,100% of CMS OPPS Rate,4.48,49.41,
"Blood test, clotting time",4025610,CDM,305,RC,85610,HCPCS,Outpatient,,,67.95,40.77,,15.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.57,70,,,percent of total billed charges,70% of total billed charges,50.96,75,,,percent of total billed charges,75% of total billed charges,7.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.01,350,,,Fee Schedule,350% of CMS OPPS Rate,4.37,102,,,Fee Schedule,102% of CMS OPPS Rate,51.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,30.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,47.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,9.86,230,,,Fee Schedule,230% of CMS OPPS Rate,32.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,61.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,61.16,
SED RATE ESR BLD,4025651,CDM,305,RC,85651,HCPCS,Outpatient,,,80.85,48.51,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.6,70,,,percent of total billed charges,70% of total billed charges,60.64,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,61.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,36.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of UHC Fee Schedule,56.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,38.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,72.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,72.77,
SEDIMENTATION RATE AUTOMATED,4025652,CDM,302,RC,85652,HCPCS,Outpatient,,,18.5,11.1,,9.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,12.95,70,,,percent of total billed charges,70% of total billed charges,13.88,75,,,percent of total billed charges,75% of total billed charges,4.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.45,350,,,Fee Schedule,350% of CMS OPPS Rate,2.75,102,,,Fee Schedule,102% of CMS OPPS Rate,14.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,8.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,3,100,,,Fee Schedule,100% of UHC Fee Schedule,12.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.21,230,,,Fee Schedule,230% of CMS OPPS Rate,8.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,16.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,16.65,
"THROMBIN TIME, PLASMA",4025675,CDM,305,RC,85670,HCPCS,Outpatient,,,107.91,64.75,,20.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.54,70,,,percent of total billed charges,70% of total billed charges,80.93,75,,,percent of total billed charges,75% of total billed charges,10.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.19,350,,,Fee Schedule,350% of CMS OPPS Rate,5.88,102,,,Fee Schedule,102% of CMS OPPS Rate,82.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of UHC Fee Schedule,75.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,230,,,Fee Schedule,230% of CMS OPPS Rate,51.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,97.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,97.12,
Coagulation assessment blood test,4025730,CDM,305,RC,85730,HCPCS,Outpatient,,,152.1,91.26,,21.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,10.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.03,350,,,Fee Schedule,350% of CMS OPPS Rate,6.13,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,136.89,
D-DIMER QUAN,4025999,CDM,305,RC,85379,HCPCS,Outpatient,,,205.2,123.12,,36.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.64,70,,,percent of total billed charges,70% of total billed charges,153.9,75,,,percent of total billed charges,75% of total billed charges,18.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,164.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.63,350,,,Fee Schedule,350% of CMS OPPS Rate,10.38,102,,,Fee Schedule,102% of CMS OPPS Rate,156.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,92.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of UHC Fee Schedule,143.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,23.41,230,,,Fee Schedule,230% of CMS OPPS Rate,98.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,184.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,184.68,
ANA(REFLEX TITER),4026038,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
Blood test to determine autoimmune disorders,4026039,CDM,302,RC,86039,HCPCS,Outpatient,,,233.2,139.92,,39.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,163.24,70,,,percent of total billed charges,70% of total billed charges,174.9,75,,,percent of total billed charges,75% of total billed charges,20.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.06,350,,,Fee Schedule,350% of CMS OPPS Rate,11.38,102,,,Fee Schedule,102% of CMS OPPS Rate,178.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.4,100,,,Fee Schedule,100% of UHC Fee Schedule,163.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,25.66,230,,,Fee Schedule,230% of CMS OPPS Rate,111.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,209.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.16,209.88,
MONONUCLEOSIS SCRN BLD,4026150,CDM,302,RC,86308,HCPCS,Outpatient,,,115.5,69.3,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,103.95,
RA(REFLEX TITER),4026160,CDM,302,RC,86430,HCPCS,Outpatient,,,94.5,56.7,,21.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,11.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.49,350,,,Fee Schedule,350% of CMS OPPS Rate,6.26,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6.14,85.05,
Blood test to screen for syphilis,4026592,CDM,302,RC,86592,HCPCS,Outpatient,,,80.55,48.33,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,61.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,38.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,72.5,
RPR TITER,4026593,CDM,302,RC,86593,HCPCS,Outpatient,,,80.55,48.33,,15.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,7.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.4,350,,,Fee Schedule,350% of CMS OPPS Rate,4.48,102,,,Fee Schedule,102% of CMS OPPS Rate,61.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of UHC Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,10.12,230,,,Fee Schedule,230% of CMS OPPS Rate,38.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.4,72.5,
HCT HEMATOCRIT BLD,4027000,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
Blood test to measure levels of hemoglobin,4027000,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
ANTI-DS DNA,4027002,CDM,302,RC,86225,HCPCS,Outpatient,,,47.3,28.38,,48.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges,35.48,75,,,percent of total billed charges,75% of total billed charges,24.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,350,,,Fee Schedule,350% of CMS OPPS Rate,14.01,102,,,Fee Schedule,102% of CMS OPPS Rate,36.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.27,100,,,Fee Schedule,100% of UHC Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,48.63,
EXTRACTABLE N AG IGG ABS,4027002,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
FIBRINOGEN PLASMA,4027003,CDM,305,RC,85384,HCPCS,Outpatient,,,73.8,44.28,,34.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,17.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.02,350,,,Fee Schedule,350% of CMS OPPS Rate,9.91,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,66.42,
PLT AGGRN -ARISTOCETIN EA (PLAVIX),4027003,CDM,305,RC,85576,HCPCS,Outpatient,,,102.15,61.29,,88.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,44.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.18,350,,,Fee Schedule,350% of CMS OPPS Rate,25.4,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,23.87,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,57.29,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.35,91.94,
COAGULOPATHY SCREEN INTERP REPORT,4027003,CDM,305,RC,85390,HCPCS,Outpatient,,,77.44,46.46,,54.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.21,70,,,percent of total billed charges,70% of total billed charges,58.08,75,,,percent of total billed charges,75% of total billed charges,27.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.18,350,,,Fee Schedule,350% of CMS OPPS Rate,15.78,102,,,Fee Schedule,102% of CMS OPPS Rate,59.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,34.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of UHC Fee Schedule,54.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,35.6,230,,,Fee Schedule,230% of CMS OPPS Rate,37.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,69.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.67,69.7,
COAGULATION TIME ACTIVATED,4027003,CDM,305,RC,85347,HCPCS,Outpatient,,,68.72,41.23,,15.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.1,70,,,percent of total billed charges,70% of total billed charges,51.54,75,,,percent of total billed charges,75% of total billed charges,7.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.98,350,,,Fee Schedule,350% of CMS OPPS Rate,4.36,102,,,Fee Schedule,102% of CMS OPPS Rate,52.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,30.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of UHC Fee Schedule,48.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,9.84,230,,,Fee Schedule,230% of CMS OPPS Rate,32.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,4.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.5,61.85,
"MALARIA SMEAR, BLD",4027207,CDM,306,RC,87207,HCPCS,Outpatient,,,63,37.8,,21.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,10.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.96,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,6.66,100,,,Fee Schedule,100% of UHC Fee Schedule,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,230,,,Fee Schedule,230% of CMS OPPS Rate,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,56.7,
BONE MARROW ASPIRATION,4027208,CDM,360,RC,38220,HCPCS,Outpatient,,,360,216,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,360,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2088.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,252,70,,,percent of total billed charges,70% of total billed charges,270,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,360,103,,,Fee Schedule,103% of CMS OPPS Rate,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,360,100,,,Fee Schedule,100% of CMS OPPS Rate,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,162,4825.85,
BM ASP WITH BM BX,4027208,CDM,761,RC,38222,HCPCS,Outpatient,,,217,130.2,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,217,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,217,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1236.82,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,162.75,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,217,103,,,Fee Schedule,103% of CMS OPPS Rate,166.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,97.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,104.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,217,100,,,Fee Schedule,100% of CMS OPPS Rate,195.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,8313.44,
CELL COUNT MISC FLUID,4029050,CDM,309,RC,89050,HCPCS,Outpatient,,,89.1,53.46,,16.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,8.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.52,350,,,Fee Schedule,350% of CMS OPPS Rate,4.81,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,5.25,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,10.85,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,100,,,Fee Schedule,100% of CMS OPPS Rate,4.72,80.19,
CELL COUNT W DIFF MISC FLUIDS,4029054,CDM,309,RC,89051,HCPCS,Outpatient,,,115.5,69.3,,19.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,10.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.59,350,,,Fee Schedule,350% of CMS OPPS Rate,5.71,102,,,Fee Schedule,102% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,6.12,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,230,,,Fee Schedule,230% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.6,103.95,
EOSINOPHILS NASAL SMEAR,4029180,CDM,309,RC,89190,HCPCS,Outpatient,,,58,34.8,,20.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.79,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,10.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.26,350,,,Fee Schedule,350% of CMS OPPS Rate,5.9,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.31,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,52.2,
"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",4030005,CDM,301,RC,80051,HCPCS,Outpatient,,,207.36,124.42,,24.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.15,70,,,percent of total billed charges,70% of total billed charges,155.52,75,,,percent of total billed charges,75% of total billed charges,12.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.53,350,,,Fee Schedule,350% of CMS OPPS Rate,7.15,102,,,Fee Schedule,102% of CMS OPPS Rate,158.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,93.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.79,100,,,Fee Schedule,100% of UHC Fee Schedule,145.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,16.12,230,,,Fee Schedule,230% of CMS OPPS Rate,99.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,186.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,186.62,
Basic metabolic panel,4030008,CDM,301,RC,80048,HCPCS,Outpatient,,,310.05,186.03,,29.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,217.04,70,,,percent of total billed charges,70% of total billed charges,232.54,75,,,percent of total billed charges,75% of total billed charges,15.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,248.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.61,350,,,Fee Schedule,350% of CMS OPPS Rate,8.62,102,,,Fee Schedule,102% of CMS OPPS Rate,237.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,139.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.4,100,,,Fee Schedule,100% of UHC Fee Schedule,217.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,19.45,230,,,Fee Schedule,230% of CMS OPPS Rate,148.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,279.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,279.05,
Prostate cancer screening; prostate specific antigen test (psa),4030014,CDM,300,RC,G0103,HCPCS,Outpatient,,,71.5,42.9,,68.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,34.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.58,350,,,Fee Schedule,350% of CMS OPPS Rate,19.69,102,,,Fee Schedule,102% of CMS OPPS Rate,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,44.41,230,,,Fee Schedule,230% of CMS OPPS Rate,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,68.35,
BASIC METABOLIC PROFILE W IONIZED CA,4030047,CDM,301,RC,80047,HCPCS,Outpatient,,,57.6,34.56,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges,43.2,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.05,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,44.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,25.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,12.36,100,,,Fee Schedule,100% of UHC Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.57,230,,,Fee Schedule,230% of CMS OPPS Rate,27.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,51.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,51.84,
General health panel,4030050,CDM,301,RC,80050,HCPCS,Outpatient,,,323.1,193.86,,,,,,Other,Not Separately reimbursable,45.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.17,70,,,percent of total billed charges,70% of total billed charges,242.33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,258.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,226.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,290.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.54,290.79,
"Blood test, comprehensive group of blood chemicals",4030054,CDM,301,RC,80053,HCPCS,Outpatient,,,504.9,302.94,,37.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges,378.68,75,,,percent of total billed charges,75% of total billed charges,19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,403.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.96,350,,,Fee Schedule,350% of CMS OPPS Rate,10.77,102,,,Fee Schedule,102% of CMS OPPS Rate,386.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,227.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,11.74,100,,,Fee Schedule,100% of UHC Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,24.28,230,,,Fee Schedule,230% of CMS OPPS Rate,242.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,454.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,454.41,
Obstetric blood test panel,4030055,CDM,300,RC,80055,HCPCS,Outpatient,,,638,382.8,,169.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,47.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,120.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,446.6,70,,,percent of total billed charges,70% of total billed charges,478.5,75,,,percent of total billed charges,75% of total billed charges,86.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,510.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,167.33,350,,,Fee Schedule,350% of CMS OPPS Rate,48.76,102,,,Fee Schedule,102% of CMS OPPS Rate,488.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,287.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,446.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,382.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.12,100,,,Fee Schedule,100% of UHC Fee Schedule,446.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,109.96,230,,,Fee Schedule,230% of CMS OPPS Rate,306.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,574.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,24.01,574.2,
Liver function blood test panel,4030060,CDM,301,RC,80076,HCPCS,Outpatient,,,425.15,255.09,,28.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,297.61,70,,,percent of total billed charges,70% of total billed charges,318.86,75,,,percent of total billed charges,75% of total billed charges,14.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,340.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.59,350,,,Fee Schedule,350% of CMS OPPS Rate,8.33,102,,,Fee Schedule,102% of CMS OPPS Rate,325.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,9.08,100,,,Fee Schedule,100% of UHC Fee Schedule,297.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,230,,,Fee Schedule,230% of CMS OPPS Rate,204.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,382.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,382.64,
"Blood test, lipids (cholesterol and triglycerides)",4030061,CDM,301,RC,80061,HCPCS,Outpatient,,,193.05,115.83,,47.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,24.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.86,350,,,Fee Schedule,350% of CMS OPPS Rate,13.65,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,30.79,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,173.75,
MYOGLOBIN ASSAY,4030095,CDM,301,RC,83874,HCPCS,Outpatient,,,262.9,157.74,,45.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.03,70,,,percent of total billed charges,70% of total billed charges,197.18,75,,,percent of total billed charges,75% of total billed charges,23.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.22,350,,,Fee Schedule,350% of CMS OPPS Rate,13.17,102,,,Fee Schedule,102% of CMS OPPS Rate,201.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,118.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14.36,100,,,Fee Schedule,100% of UHC Fee Schedule,184.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.71,230,,,Fee Schedule,230% of CMS OPPS Rate,126.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,236.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,236.61,
PAMG-1 RAPID ASSAY FOR RO,4030096,CDM,302,RC,84112,HCPCS,Outpatient,,,294,176.4,,347.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,83.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,98.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,200.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.8,70,,,percent of total billed charges,70% of total billed charges,220.5,75,,,percent of total billed charges,75% of total billed charges,176.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.38,350,,,Fee Schedule,350% of CMS OPPS Rate,100.07,102,,,Fee Schedule,102% of CMS OPPS Rate,224.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,132.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,88.3,100,,,Fee Schedule,100% of UHC Fee Schedule,205.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,225.65,230,,,Fee Schedule,230% of CMS OPPS Rate,141.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,83.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,98.11,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,347.3,
ACTH STIMULATION PANEL CORTISOL X2,4030400,CDM,301,RC,80400,HCPCS,Outpatient,,,221.95,133.17,,115.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,32.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,32.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.37,70,,,percent of total billed charges,70% of total billed charges,166.46,75,,,percent of total billed charges,75% of total billed charges,58.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.17,350,,,Fee Schedule,350% of CMS OPPS Rate,33.27,102,,,Fee Schedule,102% of CMS OPPS Rate,169.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,99.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,36.24,100,,,Fee Schedule,100% of UHC Fee Schedule,155.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,75.02,230,,,Fee Schedule,230% of CMS OPPS Rate,106.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,199.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,199.76,
HCG QUANTITATIVE SERUM,4031000,CDM,301,RC,84702,HCPCS,Outpatient,,,457.6,274.56,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,320.32,70,,,percent of total billed charges,70% of total billed charges,343.2,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,366.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,350.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,320.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,320.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,219.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,411.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,411.84,
Kidney function panel test,4031005,CDM,301,RC,80069,HCPCS,Outpatient,,,273.15,163.89,,30.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,191.21,70,,,percent of total billed charges,70% of total billed charges,204.86,75,,,percent of total billed charges,75% of total billed charges,15.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,218.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,350,,,Fee Schedule,350% of CMS OPPS Rate,8.85,102,,,Fee Schedule,102% of CMS OPPS Rate,208.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,122.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,9.65,100,,,Fee Schedule,100% of UHC Fee Schedule,191.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,19.96,230,,,Fee Schedule,230% of CMS OPPS Rate,131.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,245.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,245.84,
Test to predict likelihood of gestational diabetes,4031006,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
GTT-GLUC AFTER 3 SPECIMENS,4031006,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Prostate cancer screening; prostate specific antigen test (psa),4031014,CDM,300,RC,G0103,HCPCS,Outpatient,,,71.5,42.9,,68.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,50.05,70,,,percent of total billed charges,70% of total billed charges,53.63,75,,,percent of total billed charges,75% of total billed charges,34.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,57.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.58,350,,,Fee Schedule,350% of CMS OPPS Rate,19.69,102,,,Fee Schedule,102% of CMS OPPS Rate,54.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,32.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,50.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,44.41,230,,,Fee Schedule,230% of CMS OPPS Rate,34.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,64.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,100,,,Fee Schedule,100% of CMS OPPS Rate,11.2,68.35,
Test to measure creatinine in the urine,4031018,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
PROTEIN TOTAL URINE,4031018,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
LDL CHOLESTEROL DIRECT,4031022,CDM,301,RC,83721,HCPCS,Outpatient,,,102.15,61.29,,37.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,18.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,350,,,Fee Schedule,350% of CMS OPPS Rate,10.71,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,91.94,
"Blood test, lipids (cholesterol and triglycerides)",4031022,CDM,301,RC,80061,HCPCS,Outpatient,,,193.05,115.83,,47.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,24.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.86,350,,,Fee Schedule,350% of CMS OPPS Rate,13.65,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,30.79,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,173.75,
Blood test used to diagnose heart failure,4031030,CDM,301,RC,83880,HCPCS,Outpatient,,,187.2,112.32,,138.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges,140.4,75,,,percent of total billed charges,75% of total billed charges,70.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.41,350,,,Fee Schedule,350% of CMS OPPS Rate,40.04,102,,,Fee Schedule,102% of CMS OPPS Rate,143.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of UHC Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,90.29,230,,,Fee Schedule,230% of CMS OPPS Rate,89.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,168.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,168.48,
Blood test to measure average blood glucose levels for past 2-3 months,4031036,CDM,301,RC,83036,HCPCS,Outpatient,,,187,112.2,,34.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.71,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.9,70,,,percent of total billed charges,70% of total billed charges,140.25,75,,,percent of total billed charges,75% of total billed charges,17.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.98,350,,,Fee Schedule,350% of CMS OPPS Rate,9.9,102,,,Fee Schedule,102% of CMS OPPS Rate,143.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,84.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,10.79,100,,,Fee Schedule,100% of UHC Fee Schedule,130.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,22.33,230,,,Fee Schedule,230% of CMS OPPS Rate,89.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,168.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,168.3,
ALBUMIN BLOOD,4031040,CDM,301,RC,82040,HCPCS,Outpatient,,,90.9,54.54,,17.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,8.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,350,,,Fee Schedule,350% of CMS OPPS Rate,5.04,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,81.81,
PHENYTOIN (DILANTIN) SERUM,4031045,CDM,301,RC,80185,HCPCS,Outpatient,,,167.4,100.44,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges,125.55,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,133.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,128.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,75.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,80.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,150.66,
PHENOBARBITAL SERUM,4031046,CDM,301,RC,80184,HCPCS,Outpatient,,,167.4,100.44,,54.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges,125.55,75,,,percent of total billed charges,75% of total billed charges,27.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,133.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.55,350,,,Fee Schedule,350% of CMS OPPS Rate,15.6,102,,,Fee Schedule,102% of CMS OPPS Rate,128.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,100,,,Fee Schedule,100% of UHC Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.19,230,,,Fee Schedule,230% of CMS OPPS Rate,80.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,150.66,
"Blood test, comprehensive group of blood chemicals",4031054,CDM,301,RC,80053,HCPCS,Outpatient,,,504.9,302.94,,37.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges,378.68,75,,,percent of total billed charges,75% of total billed charges,19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,403.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.96,350,,,Fee Schedule,350% of CMS OPPS Rate,10.77,102,,,Fee Schedule,102% of CMS OPPS Rate,386.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,227.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,11.74,100,,,Fee Schedule,100% of UHC Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,24.28,230,,,Fee Schedule,230% of CMS OPPS Rate,242.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,454.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10.56,454.41,
ALCOHOL-ETHYL,4031057,CDM,301,RC,80320,HCPCS,Outpatient,,,213.3,127.98,,,,,,Other,Not Separately reimbursable,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.31,70,,,percent of total billed charges,70% of total billed charges,159.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,170.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.42,191.97,
Testing for presence of drug,4031060,CDM,301,RC,80307,HCPCS,Outpatient,,,272,163.2,,219.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,111.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.49,350,,,Fee Schedule,350% of CMS OPPS Rate,63.38,102,,,Fee Schedule,102% of CMS OPPS Rate,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,64.65,100,,,Fee Schedule,100% of UHC Fee Schedule,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.92,230,,,Fee Schedule,230% of CMS OPPS Rate,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,244.8,
"Blood test, lipids (cholesterol and triglycerides)",4031061,CDM,301,RC,80061,HCPCS,Outpatient,,,193.05,115.83,,47.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,24.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.86,350,,,Fee Schedule,350% of CMS OPPS Rate,13.65,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,30.79,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,173.75,
ALKALINE PHOSPHAT SERUM,4031075,CDM,301,RC,84075,HCPCS,Outpatient,,,90.9,54.54,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,81.81,
PHOSPHORUS INORGANIC,4031100,CDM,301,RC,84100,HCPCS,Outpatient,,,73.8,44.28,,16.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,350,,,Fee Schedule,350% of CMS OPPS Rate,4.83,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.9,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,66.42,
PHOSPHOROUS URINE 24 HR,4031105,CDM,301,RC,84105,HCPCS,Outpatient,,,101,60.6,,20.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,10.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,350,,,Fee Schedule,350% of CMS OPPS Rate,5.89,102,,,Fee Schedule,102% of CMS OPPS Rate,77.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,230,,,Fee Schedule,230% of CMS OPPS Rate,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,90.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,90.9,
POTASSIUM BLOOD,4031132,CDM,301,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
CRP (C-REACT PROT),4031140,CDM,302,RC,86140,HCPCS,Outpatient,,,78.65,47.19,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges,58.99,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,60.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,35.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,37.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,70.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,70.79,
AMYLASE,4031150,CDM,301,RC,82150,HCPCS,Outpatient,,,142.65,85.59,,22.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges,106.99,75,,,percent of total billed charges,75% of total billed charges,11.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.68,350,,,Fee Schedule,350% of CMS OPPS Rate,6.6,102,,,Fee Schedule,102% of CMS OPPS Rate,109.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,64.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of UHC Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,230,,,Fee Schedule,230% of CMS OPPS Rate,68.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,128.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,128.39,
PROTEIN SERUM,4031155,CDM,301,RC,84155,HCPCS,Outpatient,,,85.25,51.15,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges,63.94,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,65.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,38.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,40.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,76.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,76.73,
BILIRUBIN TOTAL,4031250,CDM,301,RC,82247,HCPCS,Outpatient,,,113.4,68.04,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges,85.05,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,86.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,54.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,102.06,
Measurement of direct bilirubin,4031254,CDM,301,RC,82248,HCPCS,Outpatient,,,66.15,39.69,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,59.54,
CARBAMAZEPINE SERUM,4031260,CDM,301,RC,80156,HCPCS,Outpatient,,,213.75,128.25,,51.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.63,70,,,percent of total billed charges,70% of total billed charges,160.31,75,,,percent of total billed charges,75% of total billed charges,26.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,171,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.99,350,,,Fee Schedule,350% of CMS OPPS Rate,14.86,102,,,Fee Schedule,102% of CMS OPPS Rate,163.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,96.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of UHC Fee Schedule,149.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.51,230,,,Fee Schedule,230% of CMS OPPS Rate,102.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,192.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,192.38,
SODIUM SERUM,4031295,CDM,301,RC,84295,HCPCS,Outpatient,,,73.8,44.28,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,350,,,Fee Schedule,350% of CMS OPPS Rate,4.9,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,66.42,
SODIUM URINE,4031301,CDM,301,RC,84300,HCPCS,Outpatient,,,52.2,31.32,,17.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,9.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,350,,,Fee Schedule,350% of CMS OPPS Rate,5.16,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11.63,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,46.98,
POTASSIUM URINE,4031303,CDM,301,RC,84133,HCPCS,Outpatient,,,52.2,31.32,,16.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,350,,,Fee Schedule,350% of CMS OPPS Rate,4.82,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.79,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,10.87,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,46.98,
CALCIUM SERUM,4031310,CDM,301,RC,82310,HCPCS,Outpatient,,,88.65,53.19,,18.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,9.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,350,,,Fee Schedule,350% of CMS OPPS Rate,5.26,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,79.79,
PSA (prostate specific antigen),4031316,CDM,301,RC,84153,HCPCS,Outpatient,,,77.55,46.53,,65.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.29,70,,,percent of total billed charges,70% of total billed charges,58.16,75,,,percent of total billed charges,75% of total billed charges,33.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.36,350,,,Fee Schedule,350% of CMS OPPS Rate,18.75,102,,,Fee Schedule,102% of CMS OPPS Rate,59.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,54.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.29,230,,,Fee Schedule,230% of CMS OPPS Rate,37.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,69.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,69.8,
CALCIUM URINE,4031340,CDM,301,RC,82340,HCPCS,Outpatient,,,98.1,58.86,,21.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges,73.58,75,,,percent of total billed charges,75% of total billed charges,10.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.1,350,,,Fee Schedule,350% of CMS OPPS Rate,6.15,102,,,Fee Schedule,102% of CMS OPPS Rate,75.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of UHC Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.86,230,,,Fee Schedule,230% of CMS OPPS Rate,47.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,88.29,
CO2 CARBON DIOXIDE,4031374,CDM,301,RC,82374,HCPCS,Outpatient,,,63.45,38.07,,17.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,8.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.08,350,,,Fee Schedule,350% of CMS OPPS Rate,4.97,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,11.22,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,57.11,
THEOPHYLLIN SERUM,4031420,CDM,301,RC,80198,HCPCS,Outpatient,,,121.5,72.9,,50.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges,91.13,75,,,percent of total billed charges,75% of total billed charges,25.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.49,350,,,Fee Schedule,350% of CMS OPPS Rate,14.42,102,,,Fee Schedule,102% of CMS OPPS Rate,92.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,54.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15.71,100,,,Fee Schedule,100% of UHC Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32.52,230,,,Fee Schedule,230% of CMS OPPS Rate,58.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,109.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,109.35,
CHLORIDE SERUM,4031435,CDM,301,RC,82435,HCPCS,Outpatient,,,63.45,38.07,,16.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,8.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.09,350,,,Fee Schedule,350% of CMS OPPS Rate,4.69,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,57.11,
"Blood test, thyroid stimulating hormone (TSH)",4031443,CDM,300,RC,84443,HCPCS,Outpatient,,,329.45,197.67,,59.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,230.62,70,,,percent of total billed charges,70% of total billed charges,247.09,75,,,percent of total billed charges,75% of total billed charges,30.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,263.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,350,,,Fee Schedule,350% of CMS OPPS Rate,17.13,102,,,Fee Schedule,102% of CMS OPPS Rate,252.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,148.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of UHC Fee Schedule,230.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,230,,,Fee Schedule,230% of CMS OPPS Rate,158.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,296.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,296.51,
AST OR SGOT,4031450,CDM,301,RC,84450,HCPCS,Outpatient,,,198.55,119.13,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.99,70,,,percent of total billed charges,70% of total billed charges,148.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,158.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,151.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,89.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,138.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,95.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,178.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,178.7,
Blood test to evaluate liver function,4031460,CDM,301,RC,84460,HCPCS,Outpatient,,,253,151.8,,18.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,9.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.55,350,,,Fee Schedule,350% of CMS OPPS Rate,5.4,102,,,Fee Schedule,102% of CMS OPPS Rate,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.89,100,,,Fee Schedule,100% of UHC Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.19,230,,,Fee Schedule,230% of CMS OPPS Rate,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,227.7,
CHOLESTEROL,4031465,CDM,301,RC,82465,HCPCS,Outpatient,,,111.1,66.66,,15.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.77,70,,,percent of total billed charges,70% of total billed charges,83.33,75,,,percent of total billed charges,75% of total billed charges,7.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.22,350,,,Fee Schedule,350% of CMS OPPS Rate,4.43,102,,,Fee Schedule,102% of CMS OPPS Rate,84.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,50,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.83,100,,,Fee Schedule,100% of UHC Fee Schedule,77.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,10,230,,,Fee Schedule,230% of CMS OPPS Rate,53.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,99.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,99.99,
TRIGLYCERIDES,4031478,CDM,301,RC,84478,HCPCS,Outpatient,,,121.95,73.17,,20.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,10.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.09,350,,,Fee Schedule,350% of CMS OPPS Rate,5.85,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.2,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,109.76,
TRIIODOTHYRONINE T3 FREE,4031481,CDM,301,RC,84481,HCPCS,Outpatient,,,173.25,103.95,,59.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.02,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.28,70,,,percent of total billed charges,70% of total billed charges,129.94,75,,,percent of total billed charges,75% of total billed charges,30.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.29,350,,,Fee Schedule,350% of CMS OPPS Rate,17.27,102,,,Fee Schedule,102% of CMS OPPS Rate,132.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.83,100,,,Fee Schedule,100% of UHC Fee Schedule,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,230,,,Fee Schedule,230% of CMS OPPS Rate,83.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,155.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,155.93,
BUN SERUM,4031520,CDM,301,RC,84520,HCPCS,Outpatient,,,81.95,49.17,,13.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges,61.46,75,,,percent of total billed charges,75% of total billed charges,7.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,350,,,Fee Schedule,350% of CMS OPPS Rate,4.02,102,,,Fee Schedule,102% of CMS OPPS Rate,62.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.39,100,,,Fee Schedule,100% of UHC Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,9.08,230,,,Fee Schedule,230% of CMS OPPS Rate,39.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,73.76,
CK TOTAL CREATINE KINASE SERUM,4031550,CDM,301,RC,82550,HCPCS,Outpatient,,,207,124.2,,23.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,11.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.78,350,,,Fee Schedule,350% of CMS OPPS Rate,6.64,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,14.97,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,186.3,
URIC ACID URINE,4031560,CDM,301,RC,84560,HCPCS,Outpatient,,,124.65,74.79,,17.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,9.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.78,350,,,Fee Schedule,350% of CMS OPPS Rate,5.18,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,11.68,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,112.19,
CREATININE SERUM,4031565,CDM,301,RC,82565,HCPCS,Outpatient,,,90.9,54.54,,18.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,9.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,350,,,Fee Schedule,350% of CMS OPPS Rate,5.22,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.7,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,81.81,
Test to measure creatinine in the urine,4031569,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
CREATININE CLEARANCE,4031575,CDM,301,RC,82575,HCPCS,Outpatient,,,143.55,86.13,,33.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges,107.66,75,,,percent of total billed charges,75% of total billed charges,17.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.11,350,,,Fee Schedule,350% of CMS OPPS Rate,9.64,102,,,Fee Schedule,102% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of UHC Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,21.75,230,,,Fee Schedule,230% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,129.2,
LACTIC ACID LACTATE SERUM,4031605,CDM,301,RC,83605,HCPCS,Outpatient,,,207,124.2,,40.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,20.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.49,350,,,Fee Schedule,350% of CMS OPPS Rate,11.8,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.87,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,186.3,
LDH-LACTIC DEHYDROGN,4031615,CDM,301,RC,83615,HCPCS,Outpatient,,,207,124.2,,21.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,10.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.14,350,,,Fee Schedule,350% of CMS OPPS Rate,6.16,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.71,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,13.89,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,186.3,
PROTEIN TOTAL URINE,4031691,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
Blood test to measure the level of lipoproteins in the blood,4031718,CDM,301,RC,83718,HCPCS,Outpatient,,,186,111.6,,28.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,14.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.66,350,,,Fee Schedule,350% of CMS OPPS Rate,8.35,102,,,Fee Schedule,102% of CMS OPPS Rate,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of UHC Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,18.83,230,,,Fee Schedule,230% of CMS OPPS Rate,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,167.4,
LDL CHOLESTEROL DIRECT,4031719,CDM,301,RC,83721,HCPCS,Outpatient,,,102.15,61.29,,37.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,18.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,350,,,Fee Schedule,350% of CMS OPPS Rate,10.71,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,91.94,
LITHIUM SERUM,4031725,CDM,301,RC,80178,HCPCS,Outpatient,,,88.65,53.19,,23.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,11.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,350,,,Fee Schedule,350% of CMS OPPS Rate,6.74,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.34,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,15.2,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,79.79,
MAGNESIUM SERUM,4031735,CDM,301,RC,83735,HCPCS,Outpatient,,,111.6,66.96,,23.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,12.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.45,350,,,Fee Schedule,350% of CMS OPPS Rate,6.83,102,,,Fee Schedule,102% of CMS OPPS Rate,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7.44,100,,,Fee Schedule,100% of UHC Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,15.41,230,,,Fee Schedule,230% of CMS OPPS Rate,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100.44,
Urine test to measure albumin,4031736,CDM,301,RC,82043,HCPCS,Outpatient,,,55.94,33.56,,20.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.16,70,,,percent of total billed charges,70% of total billed charges,41.96,75,,,percent of total billed charges,75% of total billed charges,10.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,350,,,Fee Schedule,350% of CMS OPPS Rate,5.89,102,,,Fee Schedule,102% of CMS OPPS Rate,42.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.43,100,,,Fee Schedule,100% of UHC Fee Schedule,39.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,230,,,Fee Schedule,230% of CMS OPPS Rate,26.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,50.35,
Quantitative measure of glucose build up in the blood over time,4031947,CDM,301,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
Test of glucose level in the blood,4031950,CDM,301,RC,82950,HCPCS,Outpatient,,,138.6,83.16,,16.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges,103.95,75,,,percent of total billed charges,75% of total billed charges,8.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.62,350,,,Fee Schedule,350% of CMS OPPS Rate,4.84,102,,,Fee Schedule,102% of CMS OPPS Rate,106.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10.92,230,,,Fee Schedule,230% of CMS OPPS Rate,66.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,124.74,
GTT-GLUC AFTER 3 SPECIMENS,4031954,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Test to predict likelihood of gestational diabetes,4031955,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
GGT GAMMA GLUTAM TRNSFRS SERUM,4031977,CDM,301,RC,82977,HCPCS,Outpatient,,,152.1,91.26,,25.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,12.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,350,,,Fee Schedule,350% of CMS OPPS Rate,7.34,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,8,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,136.89,
ACETOMINOPHEN SERUM,4032003,CDM,301,RC,80329,HCPCS,Outpatient,,,193.05,115.83,,,,,,Other,Not Separately reimbursable,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,173.75,
KETONE BODIES SERUM,4032009,CDM,301,RC,82009,HCPCS,Outpatient,,,28.35,17.01,,16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.85,70,,,percent of total billed charges,70% of total billed charges,21.26,75,,,percent of total billed charges,75% of total billed charges,8.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.81,350,,,Fee Schedule,350% of CMS OPPS Rate,4.61,102,,,Fee Schedule,102% of CMS OPPS Rate,21.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,100,,,Fee Schedule,100% of UHC Fee Schedule,19.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,10.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,25.52,
SALICYLATE,4032011,CDM,301,RC,80329,HCPCS,Outpatient,,,193.05,115.83,,,,,,Other,Not Separately reimbursable,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,173.75,
ALBUMIN BLOOD,4032040,CDM,301,RC,82040,HCPCS,Outpatient,,,90.9,54.54,,17.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,8.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,350,,,Fee Schedule,350% of CMS OPPS Rate,5.04,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,81.81,
ALBUMIN MISC SPECIMEN,4032042,CDM,301,RC,82042,HCPCS,Outpatient,,,87.75,52.65,,27.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.23,350,,,Fee Schedule,350% of CMS OPPS Rate,7.93,102,,,Fee Schedule,102% of CMS OPPS Rate,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7,100,,,Fee Schedule,100% of UHC Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,230,,,Fee Schedule,230% of CMS OPPS Rate,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,78.98,
Urine test to measure albumin-semiquantitative,4032044,CDM,300,RC,82044,HCPCS,Outpatient,,,27.46,16.48,,22.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.22,70,,,percent of total billed charges,70% of total billed charges,20.6,75,,,percent of total billed charges,75% of total billed charges,11.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.8,350,,,Fee Schedule,350% of CMS OPPS Rate,6.35,102,,,Fee Schedule,102% of CMS OPPS Rate,21.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,5.61,100,,,Fee Schedule,100% of UHC Fee Schedule,19.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,230,,,Fee Schedule,230% of CMS OPPS Rate,13.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.7,24.71,
ALCOHOL-ETHYL,4032057,CDM,301,RC,80320,HCPCS,Outpatient,,,213.3,127.98,,,,,,Other,Not Separately reimbursable,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.31,70,,,percent of total billed charges,70% of total billed charges,159.98,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,170.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.42,191.97,
Testing for presence of drug,4032060,CDM,301,RC,80307,HCPCS,Outpatient,,,272,163.2,,219.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,111.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.49,350,,,Fee Schedule,350% of CMS OPPS Rate,63.38,102,,,Fee Schedule,102% of CMS OPPS Rate,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,64.65,100,,,Fee Schedule,100% of UHC Fee Schedule,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.92,230,,,Fee Schedule,230% of CMS OPPS Rate,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,244.8,
Testing for presence of drug,4032061,CDM,301,RC,80307,HCPCS,Outpatient,,,225,135,,219.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,111.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.49,350,,,Fee Schedule,350% of CMS OPPS Rate,63.38,102,,,Fee Schedule,102% of CMS OPPS Rate,172.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,64.65,100,,,Fee Schedule,100% of UHC Fee Schedule,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.92,230,,,Fee Schedule,230% of CMS OPPS Rate,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,219.97,
AMIKACIN DRUG ASSAY,4032112,CDM,301,RC,80150,HCPCS,Outpatient,,,167.4,100.44,,53.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges,125.55,75,,,percent of total billed charges,75% of total billed charges,27.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,133.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.78,350,,,Fee Schedule,350% of CMS OPPS Rate,15.38,102,,,Fee Schedule,102% of CMS OPPS Rate,128.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,75.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of UHC Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,34.68,230,,,Fee Schedule,230% of CMS OPPS Rate,80.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,150.66,
AMMONIA PLASMA,4032140,CDM,301,RC,82140,HCPCS,Outpatient,,,105.75,63.45,,51.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.03,70,,,percent of total billed charges,70% of total billed charges,79.31,75,,,percent of total billed charges,75% of total billed charges,26.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.99,350,,,Fee Schedule,350% of CMS OPPS Rate,14.86,102,,,Fee Schedule,102% of CMS OPPS Rate,80.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,16.19,100,,,Fee Schedule,100% of UHC Fee Schedule,74.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.51,230,,,Fee Schedule,230% of CMS OPPS Rate,50.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,95.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,95.18,
AMYLASE,4032150,CDM,301,RC,82150,HCPCS,Outpatient,,,142.65,85.59,,22.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges,106.99,75,,,percent of total billed charges,75% of total billed charges,11.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.68,350,,,Fee Schedule,350% of CMS OPPS Rate,6.6,102,,,Fee Schedule,102% of CMS OPPS Rate,109.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,64.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of UHC Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,230,,,Fee Schedule,230% of CMS OPPS Rate,68.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,128.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,128.39,
Blood test to measure B-12,4032190,CDM,301,RC,82607,HCPCS,Outpatient,,,188.1,112.86,,53.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges,141.08,75,,,percent of total billed charges,75% of total billed charges,27.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,150.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.78,350,,,Fee Schedule,350% of CMS OPPS Rate,15.38,102,,,Fee Schedule,102% of CMS OPPS Rate,143.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of UHC Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,34.68,230,,,Fee Schedule,230% of CMS OPPS Rate,90.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,169.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,169.29,
BILIRUBIN TOTAL,4032250,CDM,301,RC,82247,HCPCS,Outpatient,,,113.4,68.04,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges,85.05,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,86.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,54.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,102.06,
Measurement of direct bilirubin,4032254,CDM,301,RC,82248,HCPCS,Outpatient,,,66.15,39.69,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,59.54,
CALCIUM IONIZED ABGS,4032300,CDM,301,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
CALCIUM SERUM,4032310,CDM,301,RC,82310,HCPCS,Outpatient,,,88.65,53.19,,18.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,9.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,350,,,Fee Schedule,350% of CMS OPPS Rate,5.26,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,79.79,
CALCIUM URINE,4032340,CDM,301,RC,82340,HCPCS,Outpatient,,,98.1,58.86,,21.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges,73.58,75,,,percent of total billed charges,75% of total billed charges,10.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.1,350,,,Fee Schedule,350% of CMS OPPS Rate,6.15,102,,,Fee Schedule,102% of CMS OPPS Rate,75.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of UHC Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.86,230,,,Fee Schedule,230% of CMS OPPS Rate,47.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,88.29,
CO2 CARBON DIOXIDE,4032374,CDM,301,RC,82374,HCPCS,Outpatient,,,63.45,38.07,,17.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,8.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.08,350,,,Fee Schedule,350% of CMS OPPS Rate,4.97,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,11.22,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4.88,57.11,
CHLORIDE SERUM,4032435,CDM,301,RC,82435,HCPCS,Outpatient,,,63.45,38.07,,16.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,8.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.09,350,,,Fee Schedule,350% of CMS OPPS Rate,4.69,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,57.11,
CHOLESTEROL,4032465,CDM,301,RC,82465,HCPCS,Outpatient,,,111.1,66.66,,15.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.77,70,,,percent of total billed charges,70% of total billed charges,83.33,75,,,percent of total billed charges,75% of total billed charges,7.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.22,350,,,Fee Schedule,350% of CMS OPPS Rate,4.43,102,,,Fee Schedule,102% of CMS OPPS Rate,84.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,50,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.83,100,,,Fee Schedule,100% of UHC Fee Schedule,77.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,10,230,,,Fee Schedule,230% of CMS OPPS Rate,53.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,99.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,99.99,
"CHOLINESTERASE, SERUM",4032480,CDM,301,RC,82480,HCPCS,Outpatient,,,138.5,83.1,,27.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.95,70,,,percent of total billed charges,70% of total billed charges,103.88,75,,,percent of total billed charges,75% of total billed charges,14.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.54,350,,,Fee Schedule,350% of CMS OPPS Rate,8.02,102,,,Fee Schedule,102% of CMS OPPS Rate,105.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,62.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,8.75,100,,,Fee Schedule,100% of UHC Fee Schedule,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,18.1,230,,,Fee Schedule,230% of CMS OPPS Rate,66.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.87,124.65,
VALPROIC ACID,4032520,CDM,301,RC,80164,HCPCS,Outpatient,,,180.45,108.27,,47.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges,135.34,75,,,percent of total billed charges,75% of total billed charges,24.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,144.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.39,350,,,Fee Schedule,350% of CMS OPPS Rate,13.81,102,,,Fee Schedule,102% of CMS OPPS Rate,138.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,81.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of UHC Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,31.14,230,,,Fee Schedule,230% of CMS OPPS Rate,86.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,162.41,
CORTISOL; TOTAL,4032529,CDM,300,RC,82533,HCPCS,Outpatient,,,116.1,69.66,,57.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.27,70,,,percent of total billed charges,70% of total billed charges,87.08,75,,,percent of total billed charges,75% of total billed charges,29.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.05,350,,,Fee Schedule,350% of CMS OPPS Rate,16.62,102,,,Fee Schedule,102% of CMS OPPS Rate,88.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,18.11,100,,,Fee Schedule,100% of UHC Fee Schedule,81.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,37.49,230,,,Fee Schedule,230% of CMS OPPS Rate,55.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,104.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,104.49,
CK TOTAL CREATINE KINASE SERUM,4032550,CDM,301,RC,82550,HCPCS,Outpatient,,,207,124.2,,23.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,11.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.78,350,,,Fee Schedule,350% of CMS OPPS Rate,6.64,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,14.97,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,186.3,
Blood test to detect heart enzymes,4032553,CDM,301,RC,82553,HCPCS,Outpatient,,,181.35,108.81,,40.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges,136.01,75,,,percent of total billed charges,75% of total billed charges,20.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.42,350,,,Fee Schedule,350% of CMS OPPS Rate,11.78,102,,,Fee Schedule,102% of CMS OPPS Rate,138.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.83,100,,,Fee Schedule,100% of UHC Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,26.56,230,,,Fee Schedule,230% of CMS OPPS Rate,87.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,163.22,
Blood test to measure a certain protein in the blood to determine heart muscle damage,4032554,CDM,301,RC,84484,HCPCS,Outpatient,,,360.9,216.54,,44.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,252.63,70,,,percent of total billed charges,70% of total billed charges,270.68,75,,,percent of total billed charges,75% of total billed charges,22.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,288.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.64,350,,,Fee Schedule,350% of CMS OPPS Rate,12.71,102,,,Fee Schedule,102% of CMS OPPS Rate,276.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.22,100,,,Fee Schedule,100% of UHC Fee Schedule,252.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.68,230,,,Fee Schedule,230% of CMS OPPS Rate,173.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,324.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.22,324.81,
CREATININE SERUM,4032565,CDM,301,RC,82565,HCPCS,Outpatient,,,90.9,54.54,,18.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,9.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,350,,,Fee Schedule,350% of CMS OPPS Rate,5.22,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.7,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,81.81,
Test to measure creatinine in the urine,4032569,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
CREATININE CLEARANCE,4032575,CDM,301,RC,82575,HCPCS,Outpatient,,,143.55,86.13,,33.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges,107.66,75,,,percent of total billed charges,75% of total billed charges,17.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.11,350,,,Fee Schedule,350% of CMS OPPS Rate,9.64,102,,,Fee Schedule,102% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of UHC Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,21.75,230,,,Fee Schedule,230% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,129.2,
Blood test to measure an enzyme in the blood,4032627,CDM,301,RC,82627,HCPCS,Outpatient,,,89.1,53.46,,78.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,40.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.8,350,,,Fee Schedule,350% of CMS OPPS Rate,22.67,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,51.12,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.23,80.19,
DIGOXIN SERUM,4032643,CDM,301,RC,80162,HCPCS,Outpatient,,,152.1,91.26,,47.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,23.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.48,350,,,Fee Schedule,350% of CMS OPPS Rate,13.54,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,14.75,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,30.54,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.28,136.89,
PROTEIN TOTAL URINE,4032691,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
PROTEIN TOTAL URINE EC,4032691,CDM,301,RC,84156,HCPCS,Outpatient,,,,,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,12.99,
Test to determine level of iron in the blood,4032728,CDM,301,RC,82728,HCPCS,Outpatient,,,111.1,66.66,,48.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.63,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.77,70,,,percent of total billed charges,70% of total billed charges,83.33,75,,,percent of total billed charges,75% of total billed charges,24.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.7,350,,,Fee Schedule,350% of CMS OPPS Rate,13.9,102,,,Fee Schedule,102% of CMS OPPS Rate,84.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,50,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15.15,100,,,Fee Schedule,100% of UHC Fee Schedule,77.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,31.34,230,,,Fee Schedule,230% of CMS OPPS Rate,53.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,99.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,99.99,
FOLATE FOLIC ACID SERUM,4032746,CDM,301,RC,82746,HCPCS,Outpatient,,,153.9,92.34,,52.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,107.73,70,,,percent of total billed charges,70% of total billed charges,115.43,75,,,percent of total billed charges,75% of total billed charges,26.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,123.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.45,350,,,Fee Schedule,350% of CMS OPPS Rate,14.99,102,,,Fee Schedule,102% of CMS OPPS Rate,117.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,69.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of UHC Fee Schedule,107.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,33.81,230,,,Fee Schedule,230% of CMS OPPS Rate,73.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,138.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,100,,,Fee Schedule,100% of CMS OPPS Rate,14.7,138.51,
GLUCOSE MISC SPECIMEN,4032946,CDM,301,RC,82945,HCPCS,Outpatient,,,124.65,74.79,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,112.19,
Quantitative measure of glucose build up in the blood over time,4032947,CDM,301,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
GLUCOSE BLOOD REAGENT STRIP,4032948,CDM,301,RC,82948,HCPCS,Outpatient,,,28.6,17.16,,17.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.28,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,20.02,70,,,percent of total billed charges,70% of total billed charges,21.45,75,,,percent of total billed charges,75% of total billed charges,9.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.64,350,,,Fee Schedule,350% of CMS OPPS Rate,5.14,102,,,Fee Schedule,102% of CMS OPPS Rate,21.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,4.54,100,,,Fee Schedule,100% of UHC Fee Schedule,20.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,11.59,230,,,Fee Schedule,230% of CMS OPPS Rate,13.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,25.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,100,,,Fee Schedule,100% of CMS OPPS Rate,4.07,25.74,
Test of glucose level in the blood,4032950,CDM,301,RC,82950,HCPCS,Outpatient,,,138.6,83.16,,16.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges,103.95,75,,,percent of total billed charges,75% of total billed charges,8.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.62,350,,,Fee Schedule,350% of CMS OPPS Rate,4.84,102,,,Fee Schedule,102% of CMS OPPS Rate,106.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10.92,230,,,Fee Schedule,230% of CMS OPPS Rate,66.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,124.74,
GTT-GLUC AFTER 3 SPEC,4032954,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Test to predict likelihood of gestational diabetes,4032955,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
PROTEIN TOTAL MISC SPEC,4032958,CDM,301,RC,84157,HCPCS,Outpatient,,,95.7,57.42,,14.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,7.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14,350,,,Fee Schedule,350% of CMS OPPS Rate,4.08,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of CMS OPPS Rate,9.2,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,86.13,
GGT GAMMA GLUTAM TRNSFRS SERUM,4032977,CDM,301,RC,82977,HCPCS,Outpatient,,,152.1,91.26,,25.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,12.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,350,,,Fee Schedule,350% of CMS OPPS Rate,7.34,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,8,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,136.89,
HCG QUANTITATIVE SERUM,4033000,CDM,301,RC,84702,HCPCS,Outpatient,,,457.6,274.56,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,320.32,70,,,percent of total billed charges,70% of total billed charges,343.2,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,366.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,350.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,320.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,320.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,219.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,411.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,411.84,
Test of hormone in the blood,4033001,CDM,301,RC,83001,HCPCS,Outpatient,,,113.3,67.98,,65.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,33.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.02,350,,,Fee Schedule,350% of CMS OPPS Rate,18.95,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,20.65,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,42.73,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,101.97,
Test of hormone in the blood,4033002,CDM,301,RC,83002,HCPCS,Outpatient,,,113.3,67.98,,65.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,33.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.82,350,,,Fee Schedule,350% of CMS OPPS Rate,18.89,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.57,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,42.59,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,101.97,
GROWTH HORMONE,4033003,CDM,301,RC,83003,HCPCS,Outpatient,,,131.5,78.9,,59.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,30,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.34,350,,,Fee Schedule,350% of CMS OPPS Rate,17,102,,,Fee Schedule,102% of CMS OPPS Rate,100.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of UHC Fee Schedule,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,230,,,Fee Schedule,230% of CMS OPPS Rate,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,118.35,
Kidney function panel test,4033005,CDM,301,RC,80069,HCPCS,Outpatient,,,273.15,163.89,,30.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,191.21,70,,,percent of total billed charges,70% of total billed charges,204.86,75,,,percent of total billed charges,75% of total billed charges,15.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,218.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.38,350,,,Fee Schedule,350% of CMS OPPS Rate,8.85,102,,,Fee Schedule,102% of CMS OPPS Rate,208.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,122.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,9.65,100,,,Fee Schedule,100% of UHC Fee Schedule,191.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,19.96,230,,,Fee Schedule,230% of CMS OPPS Rate,131.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,245.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,100,,,Fee Schedule,100% of CMS OPPS Rate,8.68,245.84,
Blood test to measure average blood glucose levels for past 2-3 months,4033036,CDM,301,RC,83036,HCPCS,Outpatient,,,187,112.2,,34.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.71,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.9,70,,,percent of total billed charges,70% of total billed charges,140.25,75,,,percent of total billed charges,75% of total billed charges,17.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.98,350,,,Fee Schedule,350% of CMS OPPS Rate,9.9,102,,,Fee Schedule,102% of CMS OPPS Rate,143.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,84.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,10.79,100,,,Fee Schedule,100% of UHC Fee Schedule,130.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,22.33,230,,,Fee Schedule,230% of CMS OPPS Rate,89.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,168.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,168.3,
Liver function blood test panel,4033060,CDM,301,RC,80076,HCPCS,Outpatient,,,425.15,255.09,,28.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,297.61,70,,,percent of total billed charges,70% of total billed charges,318.86,75,,,percent of total billed charges,75% of total billed charges,14.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,340.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.59,350,,,Fee Schedule,350% of CMS OPPS Rate,8.33,102,,,Fee Schedule,102% of CMS OPPS Rate,325.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,9.08,100,,,Fee Schedule,100% of UHC Fee Schedule,297.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,230,,,Fee Schedule,230% of CMS OPPS Rate,204.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,382.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,382.64,
AMMONIA PLASMA,4033140,CDM,301,RC,82140,HCPCS,Outpatient,,,105.75,63.45,,51.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.03,70,,,percent of total billed charges,70% of total billed charges,79.31,75,,,percent of total billed charges,75% of total billed charges,26.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.99,350,,,Fee Schedule,350% of CMS OPPS Rate,14.86,102,,,Fee Schedule,102% of CMS OPPS Rate,80.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,16.19,100,,,Fee Schedule,100% of UHC Fee Schedule,74.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.51,230,,,Fee Schedule,230% of CMS OPPS Rate,50.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,95.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,95.18,
CALCIUM URINE,4033340,CDM,301,RC,82340,HCPCS,Outpatient,,,98.1,58.86,,21.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges,73.58,75,,,percent of total billed charges,75% of total billed charges,10.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.1,350,,,Fee Schedule,350% of CMS OPPS Rate,6.15,102,,,Fee Schedule,102% of CMS OPPS Rate,75.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of UHC Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.86,230,,,Fee Schedule,230% of CMS OPPS Rate,47.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,88.29,
Blood test to evaluate thyroid function,4033435,CDM,301,RC,84439,HCPCS,Outpatient,,,149.05,89.43,,31.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.02,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,16.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.57,350,,,Fee Schedule,350% of CMS OPPS Rate,9.2,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,10.02,100,,,Fee Schedule,100% of UHC Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,20.74,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,134.15,
INSULIN,4033525,CDM,301,RC,83525,HCPCS,Outpatient,,,129.92,77.95,,40.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.43,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.94,70,,,percent of total billed charges,70% of total billed charges,97.44,75,,,percent of total billed charges,75% of total billed charges,20.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40,350,,,Fee Schedule,350% of CMS OPPS Rate,11.65,102,,,Fee Schedule,102% of CMS OPPS Rate,99.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,58.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,12.7,100,,,Fee Schedule,100% of UHC Fee Schedule,90.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,26.28,230,,,Fee Schedule,230% of CMS OPPS Rate,62.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,116.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,100,,,Fee Schedule,100% of CMS OPPS Rate,11.43,116.93,
Blood test to measure the amount of iron that is in transit in the body,4033545,CDM,301,RC,83540,HCPCS,Outpatient,,,118.35,71.01,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,82.85,70,,,percent of total billed charges,70% of total billed charges,88.76,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,94.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,90.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,53.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.19,100,,,Fee Schedule,100% of UHC Fee Schedule,82.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,56.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,106.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.34,106.52,
Blood test that measures the amount of iron carried in the blood,4033550,CDM,301,RC,83550,HCPCS,Outpatient,,,78.88,47.33,,30.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,59.16,75,,,percent of total billed charges,75% of total billed charges,15.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,63.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.59,350,,,Fee Schedule,350% of CMS OPPS Rate,8.91,102,,,Fee Schedule,102% of CMS OPPS Rate,60.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,20.1,230,,,Fee Schedule,230% of CMS OPPS Rate,37.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,70.99,
LACTIC ACID LACTATE SERUM,4033605,CDM,301,RC,83605,HCPCS,Outpatient,,,207,124.2,,40.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,20.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.49,350,,,Fee Schedule,350% of CMS OPPS Rate,11.8,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.87,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,186.3,
LDH-LACTIC DEHYDROGN,4033615,CDM,301,RC,83615,HCPCS,Outpatient,,,207,124.2,,21.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,10.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.14,350,,,Fee Schedule,350% of CMS OPPS Rate,6.16,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.71,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,13.89,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.04,186.3,
LIPASE SERUM,4033690,CDM,301,RC,83690,HCPCS,Outpatient,,,142.65,85.59,,24.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges,106.99,75,,,percent of total billed charges,75% of total billed charges,12.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.11,350,,,Fee Schedule,350% of CMS OPPS Rate,7.02,102,,,Fee Schedule,102% of CMS OPPS Rate,109.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,64.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,7.66,100,,,Fee Schedule,100% of UHC Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,230,,,Fee Schedule,230% of CMS OPPS Rate,68.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,128.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,128.39,
Blood test to measure the level of lipoproteins in the blood,4033718,CDM,301,RC,83718,HCPCS,Outpatient,,,186,111.6,,28.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,14.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.66,350,,,Fee Schedule,350% of CMS OPPS Rate,8.35,102,,,Fee Schedule,102% of CMS OPPS Rate,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of UHC Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,18.83,230,,,Fee Schedule,230% of CMS OPPS Rate,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,167.4,
LDL CHOLESTEROL DIRECT,4033719,CDM,301,RC,83721,HCPCS,Outpatient,,,102.15,61.29,,37.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,18.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,350,,,Fee Schedule,350% of CMS OPPS Rate,10.71,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,91.94,
LITHIUM SERUM,4033725,CDM,301,RC,80178,HCPCS,Outpatient,,,88.65,53.19,,23.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,11.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,350,,,Fee Schedule,350% of CMS OPPS Rate,6.74,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.34,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,15.2,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,79.79,
MAGNESIUM ASSAY,4033735,CDM,301,RC,83735,HCPCS,Outpatient,,,111.6,66.96,,23.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,12.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.45,350,,,Fee Schedule,350% of CMS OPPS Rate,6.83,102,,,Fee Schedule,102% of CMS OPPS Rate,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7.44,100,,,Fee Schedule,100% of UHC Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,15.41,230,,,Fee Schedule,230% of CMS OPPS Rate,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100.44,
Urine test to measure albumin,4033736,CDM,301,RC,82043,HCPCS,Outpatient,,,55.94,33.56,,20.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.16,70,,,percent of total billed charges,70% of total billed charges,41.96,75,,,percent of total billed charges,75% of total billed charges,10.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,350,,,Fee Schedule,350% of CMS OPPS Rate,5.89,102,,,Fee Schedule,102% of CMS OPPS Rate,42.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.43,100,,,Fee Schedule,100% of UHC Fee Schedule,39.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,230,,,Fee Schedule,230% of CMS OPPS Rate,26.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,50.35,
OSMOLALITY SERUM,4033930,CDM,301,RC,83930,HCPCS,Outpatient,,,66.15,39.69,,23.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,11.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,350,,,Fee Schedule,350% of CMS OPPS Rate,6.74,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,7.34,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,15.2,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,59.54,
OSMOLALITY URINE,4033935,CDM,301,RC,83935,HCPCS,Outpatient,,,52.2,31.32,,24.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.82,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,12.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.87,350,,,Fee Schedule,350% of CMS OPPS Rate,6.95,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,46.98,
Test of glucose level in the blood,4033950,CDM,301,RC,82950,HCPCS,Outpatient,,,138.6,83.16,,16.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges,103.95,75,,,percent of total billed charges,75% of total billed charges,8.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.62,350,,,Fee Schedule,350% of CMS OPPS Rate,4.84,102,,,Fee Schedule,102% of CMS OPPS Rate,106.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10.92,230,,,Fee Schedule,230% of CMS OPPS Rate,66.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,124.74,
PARATHORMONE,4033970,CDM,301,RC,83970,HCPCS,Outpatient,,,124,74.4,,146.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,103.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,74.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.48,350,,,Fee Schedule,350% of CMS OPPS Rate,42.1,102,,,Fee Schedule,102% of CMS OPPS Rate,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,45.86,100,,,Fee Schedule,100% of UHC Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,94.94,230,,,Fee Schedule,230% of CMS OPPS Rate,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,146.13,
"PH, MISC FLUID",4033986,CDM,301,RC,83986,HCPCS,Outpatient,,,44.55,26.73,,12.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.19,70,,,percent of total billed charges,70% of total billed charges,33.41,75,,,percent of total billed charges,75% of total billed charges,6.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,350,,,Fee Schedule,350% of CMS OPPS Rate,3.65,102,,,Fee Schedule,102% of CMS OPPS Rate,34.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of UHC Fee Schedule,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,230,,,Fee Schedule,230% of CMS OPPS Rate,21.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,40.1,
Blood test used to diagnose heart failure,4034030,CDM,301,RC,83880,HCPCS,Outpatient,,,187.2,112.32,,138.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges,140.4,75,,,percent of total billed charges,75% of total billed charges,70.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.41,350,,,Fee Schedule,350% of CMS OPPS Rate,40.04,102,,,Fee Schedule,102% of CMS OPPS Rate,143.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of UHC Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,90.29,230,,,Fee Schedule,230% of CMS OPPS Rate,89.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,168.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,168.48,
PHENYTOIN (DILANTIN) SERUM,4034045,CDM,301,RC,80185,HCPCS,Outpatient,,,167.4,100.44,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges,125.55,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,133.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,128.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,75.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,80.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,150.66,
PHENOBARBITAL SERUM,4034046,CDM,301,RC,80184,HCPCS,Outpatient,,,167.4,100.44,,54.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges,125.55,75,,,percent of total billed charges,75% of total billed charges,27.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,133.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.55,350,,,Fee Schedule,350% of CMS OPPS Rate,15.6,102,,,Fee Schedule,102% of CMS OPPS Rate,128.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,100,,,Fee Schedule,100% of UHC Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.19,230,,,Fee Schedule,230% of CMS OPPS Rate,80.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,150.66,
ALKALINE PHOSPHAT SERUM,4034075,CDM,301,RC,84075,HCPCS,Outpatient,,,90.9,54.54,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,81.81,
Blood test to measure level of prealbumin,4034080,CDM,301,RC,84134,HCPCS,Outpatient,,,44,26.4,,51.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,26.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14.88,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,100,,,Fee Schedule,100% of UHC Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,33.55,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,6.81,51.64,
PHOSPHORUS INORGANIC,4034100,CDM,301,RC,84100,HCPCS,Outpatient,,,73.8,44.28,,16.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,350,,,Fee Schedule,350% of CMS OPPS Rate,4.83,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.9,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,66.42,
PHOSPHOROUS URINE 24 HR,4034105,CDM,301,RC,84105,HCPCS,Outpatient,,,101,60.6,,20.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,10.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,350,,,Fee Schedule,350% of CMS OPPS Rate,5.89,102,,,Fee Schedule,102% of CMS OPPS Rate,77.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,230,,,Fee Schedule,230% of CMS OPPS Rate,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,90.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,90.9,
POTASSIUM BLOOD,4034132,CDM,301,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
PROGESTERONE SERUM,4034144,CDM,301,RC,84144,HCPCS,Outpatient,,,113.3,67.98,,73.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,37.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.01,350,,,Fee Schedule,350% of CMS OPPS Rate,21.27,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,23.18,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,47.97,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,100,,,Fee Schedule,100% of CMS OPPS Rate,20.86,101.97,
PROLACTIN SERUM,4034146,CDM,301,RC,84146,HCPCS,Outpatient,,,113.3,67.98,,68.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,34.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.83,350,,,Fee Schedule,350% of CMS OPPS Rate,19.76,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,21.53,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,44.57,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,101.97,
PROTEIN SERUM,4034155,CDM,301,RC,84155,HCPCS,Outpatient,,,85.25,51.15,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges,63.94,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,65.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,38.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,40.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,76.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,76.73,
SODIUM SERUM,4034295,CDM,301,RC,84295,HCPCS,Outpatient,,,73.8,44.28,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,350,,,Fee Schedule,350% of CMS OPPS Rate,4.9,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,66.42,
SODIUM URINE,4034301,CDM,301,RC,84300,HCPCS,Outpatient,,,52.2,31.32,,17.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,9.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,350,,,Fee Schedule,350% of CMS OPPS Rate,5.16,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11.63,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,46.98,
POTASSIUM URINE,4034303,CDM,301,RC,84133,HCPCS,Outpatient,,,52.2,31.32,,16.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,350,,,Fee Schedule,350% of CMS OPPS Rate,4.82,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.79,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,10.87,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,46.98,
CHLORIDE URINE,4034306,CDM,301,RC,82436,HCPCS,Outpatient,,,88.65,53.19,,20.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,10.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,350,,,Fee Schedule,350% of CMS OPPS Rate,5.86,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.59,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.59,79.79,
SODIUM MISC SPECIMEN,4034310,CDM,301,RC,84302,HCPCS,Outpatient,,,57.6,34.56,,17.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges,43.2,75,,,percent of total billed charges,75% of total billed charges,8.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.01,350,,,Fee Schedule,350% of CMS OPPS Rate,4.95,102,,,Fee Schedule,102% of CMS OPPS Rate,44.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,25.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,100% of UHC Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,230,,,Fee Schedule,230% of CMS OPPS Rate,27.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,51.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4.86,51.84,
CHLORIDE MISC SPECIMEN,4034314,CDM,301,RC,82438,HCPCS,Outpatient,,,64,38.4,,17.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.5,350,,,Fee Schedule,350% of CMS OPPS Rate,5.1,102,,,Fee Schedule,102% of CMS OPPS Rate,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.43,100,,,Fee Schedule,100% of UHC Fee Schedule,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5,100,,,Fee Schedule,100% of CMS OPPS Rate,11.5,230,,,Fee Schedule,230% of CMS OPPS Rate,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5,100,,,Fee Schedule,100% of CMS OPPS Rate,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,100,,,Fee Schedule,100% of CMS OPPS Rate,5,57.6,
TESTOSTERONE SERUM,4034403,CDM,301,RC,84403,HCPCS,Outpatient,,,113.3,67.98,,91.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,46.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.33,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,28.68,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.36,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,101.97,
THEOPHYLLIN SERUM,4034420,CDM,301,RC,80198,HCPCS,Outpatient,,,121.5,72.9,,50.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges,91.13,75,,,percent of total billed charges,75% of total billed charges,25.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.49,350,,,Fee Schedule,350% of CMS OPPS Rate,14.42,102,,,Fee Schedule,102% of CMS OPPS Rate,92.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,54.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15.71,100,,,Fee Schedule,100% of UHC Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32.52,230,,,Fee Schedule,230% of CMS OPPS Rate,58.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,109.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,109.35,
T3 RESIN UPTAKE SERUM,4034434,CDM,301,RC,84479,HCPCS,Outpatient,,,143.55,86.13,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.66,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.18,100,,,Fee Schedule,100% of UHC Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.69,129.2,
Blood test to evaluate thyroid function,4034435,CDM,301,RC,84439,HCPCS,Outpatient,,,149.05,89.43,,31.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.02,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,16.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.57,350,,,Fee Schedule,350% of CMS OPPS Rate,9.2,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,10.02,100,,,Fee Schedule,100% of UHC Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,20.74,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,100,,,Fee Schedule,100% of CMS OPPS Rate,9.02,134.15,
Blood test to measure a type of thyroid hormone,4034436,CDM,301,RC,84436,HCPCS,Outpatient,,,157.95,94.77,,24.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges,118.46,75,,,percent of total billed charges,75% of total billed charges,12.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.04,350,,,Fee Schedule,350% of CMS OPPS Rate,7,102,,,Fee Schedule,102% of CMS OPPS Rate,120.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.63,100,,,Fee Schedule,100% of UHC Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,15.8,230,,,Fee Schedule,230% of CMS OPPS Rate,75.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,142.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,142.16,
"Blood test, thyroid stimulating hormone (TSH)",4034443,CDM,300,RC,84443,HCPCS,Outpatient,,,329.45,197.67,,59.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,230.62,70,,,percent of total billed charges,70% of total billed charges,247.09,75,,,percent of total billed charges,75% of total billed charges,30.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,263.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,350,,,Fee Schedule,350% of CMS OPPS Rate,17.13,102,,,Fee Schedule,102% of CMS OPPS Rate,252.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,148.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of UHC Fee Schedule,230.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,230,,,Fee Schedule,230% of CMS OPPS Rate,158.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,296.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,296.51,
AST OR SGOT,4034450,CDM,301,RC,84450,HCPCS,Outpatient,,,198.55,119.13,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.99,70,,,percent of total billed charges,70% of total billed charges,148.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,158.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,151.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,89.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,138.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,95.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,178.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,178.7,
Blood test to evaluate liver function,4034460,CDM,301,RC,84460,HCPCS,Outpatient,,,253,151.8,,18.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,9.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.55,350,,,Fee Schedule,350% of CMS OPPS Rate,5.4,102,,,Fee Schedule,102% of CMS OPPS Rate,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.89,100,,,Fee Schedule,100% of UHC Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.19,230,,,Fee Schedule,230% of CMS OPPS Rate,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,227.7,
TRANSFERRIN,4034466,CDM,301,RC,84466,HCPCS,Outpatient,,,210.1,126.06,,45.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,147.07,70,,,percent of total billed charges,70% of total billed charges,157.58,75,,,percent of total billed charges,75% of total billed charges,22.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,168.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.66,350,,,Fee Schedule,350% of CMS OPPS Rate,13.01,102,,,Fee Schedule,102% of CMS OPPS Rate,160.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of UHC Fee Schedule,147.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,29.34,230,,,Fee Schedule,230% of CMS OPPS Rate,100.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,189.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,189.09,
TRIGLYCERIDES,4034478,CDM,301,RC,84478,HCPCS,Outpatient,,,121.95,73.17,,20.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,10.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.09,350,,,Fee Schedule,350% of CMS OPPS Rate,5.85,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.2,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,109.76,
TRIIODOTHYRONINE T3 FREE,4034481,CDM,301,RC,84481,HCPCS,Outpatient,,,173.25,103.95,,59.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.02,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.28,70,,,percent of total billed charges,70% of total billed charges,129.94,75,,,percent of total billed charges,75% of total billed charges,30.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.29,350,,,Fee Schedule,350% of CMS OPPS Rate,17.27,102,,,Fee Schedule,102% of CMS OPPS Rate,132.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.83,100,,,Fee Schedule,100% of UHC Fee Schedule,121.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,230,,,Fee Schedule,230% of CMS OPPS Rate,83.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,155.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,155.93,
BUN SERUM,4034520,CDM,301,RC,84520,HCPCS,Outpatient,,,81.95,49.17,,13.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges,61.46,75,,,percent of total billed charges,75% of total billed charges,7.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,350,,,Fee Schedule,350% of CMS OPPS Rate,4.02,102,,,Fee Schedule,102% of CMS OPPS Rate,62.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.39,100,,,Fee Schedule,100% of UHC Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,9.08,230,,,Fee Schedule,230% of CMS OPPS Rate,39.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,73.76,
UREA NITROGEN URINE,4034523,CDM,301,RC,84540,HCPCS,Outpatient,,,69.75,41.85,,19.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,10,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.45,350,,,Fee Schedule,350% of CMS OPPS Rate,5.67,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,12.78,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,62.78,
URIC ACID SERUM,4034550,CDM,301,RC,84550,HCPCS,Outpatient,,,124.65,74.79,,16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,8.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.81,350,,,Fee Schedule,350% of CMS OPPS Rate,4.61,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,10.39,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,112.19,
URIC ACID URINE,4034560,CDM,301,RC,84560,HCPCS,Outpatient,,,124.65,74.79,,17.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,9.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.78,350,,,Fee Schedule,350% of CMS OPPS Rate,5.18,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,11.68,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,112.19,
VANCOMYCIN DRUG ASSAY,4034570,CDM,301,RC,80202,HCPCS,Outpatient,,,152.1,91.26,,47.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,24.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.39,350,,,Fee Schedule,350% of CMS OPPS Rate,13.81,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,31.14,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,136.89,
VOLUME MEASURE URINE,4034600,CDM,307,RC,81050,HCPCS,Outpatient,,,11.25,6.75,,12.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges,8.44,75,,,percent of total billed charges,75% of total billed charges,6.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.74,350,,,Fee Schedule,350% of CMS OPPS Rate,3.71,102,,,Fee Schedule,102% of CMS OPPS Rate,8.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,5.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.34,100,,,Fee Schedule,100% of UHC Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,8.37,230,,,Fee Schedule,230% of CMS OPPS Rate,5.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.34,12.88,
GENTAMYCIN DRUG ASSAY,4034695,CDM,301,RC,80170,HCPCS,Outpatient,,,121.95,73.17,,57.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,29.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.33,350,,,Fee Schedule,350% of CMS OPPS Rate,16.7,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,18.2,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,37.67,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,16.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,109.76,
Test to measure arterial blood gases,4034700,CDM,301,RC,82803,HCPCS,Outpatient,,,290.79,174.47,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges,218.09,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,222.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of UHC Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,139.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,261.71,
COHGB CARBOXYHEMOGLOBIN,4034708,CDM,301,RC,82375,HCPCS,Outpatient,,,106.15,63.69,,43.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,22.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.12,350,,,Fee Schedule,350% of CMS OPPS Rate,12.56,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,13.69,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,28.33,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.32,95.54,
"METHEMOGLOBIN, BLD",4034709,CDM,301,RC,83050,HCPCS,Outpatient,,,63.45,38.07,,29.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,14.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.69,350,,,Fee Schedule,350% of CMS OPPS Rate,8.36,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.15,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,18.85,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.19,100,,,Fee Schedule,100% of CMS OPPS Rate,8.15,57.11,
TOBRAMYCIN DRUG ASSAY,4034810,CDM,301,RC,80200,HCPCS,Outpatient,,,121.95,73.17,,57.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,29.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.45,350,,,Fee Schedule,350% of CMS OPPS Rate,16.45,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.09,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,16.13,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,109.76,
CRP (C-REACT PROT),4036140,CDM,302,RC,86140,HCPCS,Outpatient,,,78.65,47.19,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges,58.99,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,60.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,35.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,37.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,70.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,70.79,
CRP - HIGH SENSITIVITY,4036141,CDM,302,RC,86141,HCPCS,Outpatient,,,167.75,100.65,,45.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.43,70,,,percent of total billed charges,70% of total billed charges,125.81,75,,,percent of total billed charges,75% of total billed charges,23.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,134.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.32,350,,,Fee Schedule,350% of CMS OPPS Rate,13.2,102,,,Fee Schedule,102% of CMS OPPS Rate,128.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,75.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of UHC Fee Schedule,117.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,29.78,230,,,Fee Schedule,230% of CMS OPPS Rate,80.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,150.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,150.98,
"CEA, SERUM",4036151,CDM,301,RC,82378,HCPCS,Outpatient,,,200.75,120.45,,67.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.96,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140.53,70,,,percent of total billed charges,70% of total billed charges,150.56,75,,,percent of total billed charges,75% of total billed charges,34.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,160.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.36,350,,,Fee Schedule,350% of CMS OPPS Rate,19.33,102,,,Fee Schedule,102% of CMS OPPS Rate,153.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,90.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of UHC Fee Schedule,140.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,43.6,230,,,Fee Schedule,230% of CMS OPPS Rate,96.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,180.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.96,180.68,
"IA, QUANT; CA 19-9",4036301,CDM,302,RC,86301,HCPCS,Outpatient,,,198.45,119.07,,73.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.92,70,,,percent of total billed charges,70% of total billed charges,148.84,75,,,percent of total billed charges,75% of total billed charges,37.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,158.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,350,,,Fee Schedule,350% of CMS OPPS Rate,21.22,102,,,Fee Schedule,102% of CMS OPPS Rate,151.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,89.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of UHC Fee Schedule,138.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.86,230,,,Fee Schedule,230% of CMS OPPS Rate,95.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,178.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,178.61,
Blood test to monitor for cancer,4036304,CDM,302,RC,86304,HCPCS,Outpatient,,,207.9,124.74,,73.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.53,70,,,percent of total billed charges,70% of total billed charges,155.93,75,,,percent of total billed charges,75% of total billed charges,37.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,166.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,350,,,Fee Schedule,350% of CMS OPPS Rate,21.22,102,,,Fee Schedule,102% of CMS OPPS Rate,159.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,93.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of UHC Fee Schedule,145.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.86,230,,,Fee Schedule,230% of CMS OPPS Rate,99.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,187.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,187.11,
PSA (prostate specific antigen),4036316,CDM,301,RC,84153,HCPCS,Outpatient,,,77.55,46.53,,65.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.29,70,,,percent of total billed charges,70% of total billed charges,58.16,75,,,percent of total billed charges,75% of total billed charges,33.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.36,350,,,Fee Schedule,350% of CMS OPPS Rate,18.75,102,,,Fee Schedule,102% of CMS OPPS Rate,59.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,54.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.29,230,,,Fee Schedule,230% of CMS OPPS Rate,37.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,69.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,69.8,
ALBUMIN BLOOD,4037002,CDM,301,RC,82040,HCPCS,Outpatient,,,90.9,54.54,,17.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,8.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,350,,,Fee Schedule,350% of CMS OPPS Rate,5.04,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,81.81,
PROTEIN SERUM,4037002,CDM,301,RC,84155,HCPCS,Outpatient,,,85.25,51.15,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges,63.94,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,65.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,38.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,40.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,76.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,76.73,
Quantitative measure of glucose build up in the blood over time,4037003,CDM,301,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
Blood test to measure levels of hemoglobin,4037003,CDM,305,RC,85018,HCPCS,Outpatient,,,52.2,31.32,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,46.98,
HCT HEMATOCRIT BLD,4037003,CDM,305,RC,85014,HCPCS,Outpatient,,,66.15,39.69,,8.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,4.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.29,350,,,Fee Schedule,350% of CMS OPPS Rate,2.41,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.64,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5.45,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,59.54,
CALCIUM IONIZED ABGS,4037003,CDM,301,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
POTASSIUM BLOOD,4037003,CDM,301,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
Test to measure arterial blood gases,4037003,CDM,301,RC,82803,HCPCS,Outpatient,,,290.79,174.47,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges,218.09,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,222.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of UHC Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,139.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,261.71,
GLUCOSE MISC SPECIMEN,4037004,CDM,301,RC,82945,HCPCS,Outpatient,,,124.65,74.79,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,112.19,
PROTEIN TOTAL MISC SPEC,4037004,CDM,301,RC,84157,HCPCS,Outpatient,,,95.7,57.42,,14.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,7.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14,350,,,Fee Schedule,350% of CMS OPPS Rate,4.08,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of CMS OPPS Rate,9.2,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,4,86.13,
Blood test to measure the amount of iron that is in transit in the body,4037005,CDM,301,RC,83540,HCPCS,Outpatient,,,118.35,71.01,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,82.85,70,,,percent of total billed charges,70% of total billed charges,88.76,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,94.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,90.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,53.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.19,100,,,Fee Schedule,100% of UHC Fee Schedule,82.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,56.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,106.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.34,106.52,
Blood test that measures the amount of iron carried in the blood,4037005,CDM,301,RC,83550,HCPCS,Outpatient,,,78.88,47.33,,30.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,59.16,75,,,percent of total billed charges,75% of total billed charges,15.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,63.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.59,350,,,Fee Schedule,350% of CMS OPPS Rate,8.91,102,,,Fee Schedule,102% of CMS OPPS Rate,60.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,35.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,20.1,230,,,Fee Schedule,230% of CMS OPPS Rate,37.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,100,,,Fee Schedule,100% of CMS OPPS Rate,8.74,70.99,
Test to predict likelihood of gestational diabetes,4037006,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
GTT-GLUC AFTER 3 SPEC,4037006,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
GTT-GLUC AFTER 3 SPEC,4037007,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Test to predict likelihood of gestational diabetes,4037007,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
Automated urinalysis test,4037007,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
GTT-GLUC AFTER 3 SPEC,4037008,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Test to predict likelihood of gestational diabetes,4037008,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
Automated urinalysis test,4037008,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
Test to predict likelihood of gestational diabetes,4037009,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
GTT-GLUC AFTER 3 SPEC,4037009,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Test to predict likelihood of gestational diabetes,4037010,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
GTT-GLUC AFTER 3 SPEC,4037010,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Automated urinalysis test,4037011,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
GTT-GLUC AFTER 3 SPEC,4037011,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Test to predict likelihood of gestational diabetes,4037011,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
Test to predict likelihood of gestational diabetes,4037012,CDM,301,RC,82951,HCPCS,Outpatient,,,121.05,72.63,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,108.95,
Automated urinalysis test,4037012,CDM,307,RC,81003,HCPCS,Outpatient,,,89.1,53.46,,7.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,4.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,350,,,Fee Schedule,350% of CMS OPPS Rate,2.29,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.49,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.17,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80.19,
GTT-GLUC AFTER 3 SPEC,4037012,CDM,301,RC,82952,HCPCS,Outpatient,,,47.25,28.35,,13.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,7.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,350,,,Fee Schedule,350% of CMS OPPS Rate,3.99,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4.36,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3.92,42.53,
Blood test to detect heart enzymes,4037013,CDM,301,RC,82553,HCPCS,Outpatient,,,181.35,108.81,,40.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges,136.01,75,,,percent of total billed charges,75% of total billed charges,20.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.42,350,,,Fee Schedule,350% of CMS OPPS Rate,11.78,102,,,Fee Schedule,102% of CMS OPPS Rate,138.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.83,100,,,Fee Schedule,100% of UHC Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,26.56,230,,,Fee Schedule,230% of CMS OPPS Rate,87.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,163.22,
CK TOTAL CREATINE KINASE SERUM,4037013,CDM,301,RC,82550,HCPCS,Outpatient,,,207,124.2,,23.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,11.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.78,350,,,Fee Schedule,350% of CMS OPPS Rate,6.64,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.24,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,14.97,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,100,,,Fee Schedule,100% of CMS OPPS Rate,6.51,186.3,
SODIUM SERUM,4037014,CDM,301,RC,84295,HCPCS,Outpatient,,,73.8,44.28,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,350,,,Fee Schedule,350% of CMS OPPS Rate,4.9,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,66.42,
CALCIUM SERUM,4037014,CDM,301,RC,82310,HCPCS,Outpatient,,,88.65,53.19,,18.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,9.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,350,,,Fee Schedule,350% of CMS OPPS Rate,5.26,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,79.79,
POTASSIUM BLOOD,4037014,CDM,301,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
Blood test to measure a type of thyroid hormone,4037015,CDM,301,RC,84436,HCPCS,Outpatient,,,157.95,94.77,,24.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges,118.46,75,,,percent of total billed charges,75% of total billed charges,12.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.04,350,,,Fee Schedule,350% of CMS OPPS Rate,7,102,,,Fee Schedule,102% of CMS OPPS Rate,120.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.63,100,,,Fee Schedule,100% of UHC Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,15.8,230,,,Fee Schedule,230% of CMS OPPS Rate,75.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,142.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,6.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,142.16,
T3 RESIN UPTAKE SERUM,4037015,CDM,301,RC,84479,HCPCS,Outpatient,,,143.55,86.13,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.66,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.18,100,,,Fee Schedule,100% of UHC Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.69,129.2,
Measurement of direct bilirubin,4037016,CDM,301,RC,82248,HCPCS,Outpatient,,,66.15,39.69,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,59.54,
BILIRUBIN TOTAL,4037016,CDM,301,RC,82247,HCPCS,Outpatient,,,113.4,68.04,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges,85.05,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,86.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,54.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,102.06,
AST OR SGOT,4037017,CDM,301,RC,84450,HCPCS,Outpatient,,,198.55,119.13,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.99,70,,,percent of total billed charges,70% of total billed charges,148.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,158.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,151.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,89.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,138.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,95.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,178.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,178.7,
CREATININE SERUM,4037017,CDM,301,RC,82565,HCPCS,Outpatient,,,90.9,54.54,,18.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,9.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,350,,,Fee Schedule,350% of CMS OPPS Rate,5.22,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.7,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,81.81,
URIC ACID SERUM,4037017,CDM,301,RC,84550,HCPCS,Outpatient,,,124.65,74.79,,16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,8.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.81,350,,,Fee Schedule,350% of CMS OPPS Rate,4.61,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,10.39,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,112.19,
Blood test to evaluate liver function,4037017,CDM,301,RC,84460,HCPCS,Outpatient,,,253,151.8,,18.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,9.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.55,350,,,Fee Schedule,350% of CMS OPPS Rate,5.4,102,,,Fee Schedule,102% of CMS OPPS Rate,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.89,100,,,Fee Schedule,100% of UHC Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.19,230,,,Fee Schedule,230% of CMS OPPS Rate,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,227.7,
BILIRUBIN TOTAL,4037017,CDM,301,RC,82247,HCPCS,Outpatient,,,113.4,68.04,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges,85.05,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,86.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,54.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,102.06,
PROTEIN TOTAL URINE,4037018,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
Test to measure creatinine in the urine,4037018,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
Blood test to determine infection with Hepatitis C,4037020,CDM,302,RC,86803,HCPCS,Outpatient,,,188.1,112.86,,50.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges,141.08,75,,,percent of total billed charges,75% of total billed charges,25.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,150.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.94,350,,,Fee Schedule,350% of CMS OPPS Rate,14.55,102,,,Fee Schedule,102% of CMS OPPS Rate,143.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.85,100,,,Fee Schedule,100% of UHC Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,32.82,230,,,Fee Schedule,230% of CMS OPPS Rate,90.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,169.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,169.29,
HEP B SURFACE AG,4037020,CDM,306,RC,87340,HCPCS,Outpatient,,,169.2,101.52,,36.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.44,70,,,percent of total billed charges,70% of total billed charges,126.9,75,,,percent of total billed charges,75% of total billed charges,18.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.15,350,,,Fee Schedule,350% of CMS OPPS Rate,10.53,102,,,Fee Schedule,102% of CMS OPPS Rate,129.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,76.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,100,,,Fee Schedule,100% of UHC Fee Schedule,118.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.75,230,,,Fee Schedule,230% of CMS OPPS Rate,81.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,152.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,152.28,
HEP B SURFACE AB,4037020,CDM,302,RC,86706,HCPCS,Outpatient,,,190.85,114.51,,38.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133.6,70,,,percent of total billed charges,70% of total billed charges,143.14,75,,,percent of total billed charges,75% of total billed charges,19.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.59,350,,,Fee Schedule,350% of CMS OPPS Rate,10.95,102,,,Fee Schedule,102% of CMS OPPS Rate,146,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,85.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of UHC Fee Schedule,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.7,230,,,Fee Schedule,230% of CMS OPPS Rate,91.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,171.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,171.77,
LDL CHOLESTEROL DIRECT,4037022,CDM,301,RC,83721,HCPCS,Outpatient,,,102.15,61.29,,37.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,18.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,350,,,Fee Schedule,350% of CMS OPPS Rate,10.71,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10.42,91.94,
"Blood test, lipids (cholesterol and triglycerides)",4037022,CDM,301,RC,80061,HCPCS,Outpatient,,,193.05,115.83,,47.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,24.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.86,350,,,Fee Schedule,350% of CMS OPPS Rate,13.65,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,30.79,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,173.75,
UREA NITROGEN URINE,4037023,CDM,301,RC,84540,HCPCS,Outpatient,,,69.75,41.85,,19.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,10,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.45,350,,,Fee Schedule,350% of CMS OPPS Rate,5.67,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,12.78,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,62.78,
BUN SERUM,4037023,CDM,301,RC,84520,HCPCS,Outpatient,,,81.95,49.17,,13.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges,61.46,75,,,percent of total billed charges,75% of total billed charges,7.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,350,,,Fee Schedule,350% of CMS OPPS Rate,4.02,102,,,Fee Schedule,102% of CMS OPPS Rate,62.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.39,100,,,Fee Schedule,100% of UHC Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,9.08,230,,,Fee Schedule,230% of CMS OPPS Rate,39.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,73.76,
CREATININE SERUM,4037023,CDM,301,RC,82565,HCPCS,Outpatient,,,90.9,54.54,,18.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,9.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,350,,,Fee Schedule,350% of CMS OPPS Rate,5.22,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.7,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.12,81.81,
Test to measure creatinine in the urine,4037023,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
Blood test to determine if antibodies exist for rubella,4039009,CDM,302,RC,86762,HCPCS,Outpatient,,,43,25.8,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,50.94,
CARBAMAZEPINE SERUM,4039260,CDM,301,RC,80156,HCPCS,Outpatient,,,213.75,128.25,,51.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.63,70,,,percent of total billed charges,70% of total billed charges,160.31,75,,,percent of total billed charges,75% of total billed charges,26.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,171,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.99,350,,,Fee Schedule,350% of CMS OPPS Rate,14.86,102,,,Fee Schedule,102% of CMS OPPS Rate,163.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,96.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of UHC Fee Schedule,149.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.51,230,,,Fee Schedule,230% of CMS OPPS Rate,102.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,192.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,192.38,
VALPROIC ACID,4039520,CDM,301,RC,80164,HCPCS,Outpatient,,,180.45,108.27,,47.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges,135.34,75,,,percent of total billed charges,75% of total billed charges,24.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,144.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.39,350,,,Fee Schedule,350% of CMS OPPS Rate,13.81,102,,,Fee Schedule,102% of CMS OPPS Rate,138.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,81.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of UHC Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,31.14,230,,,Fee Schedule,230% of CMS OPPS Rate,86.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,13.54,162.41,
SURG/PATH GR&MICRO PROSTATE NEEDLE BX,4060021,CDM,314,RC,G0416,HCPCS,Outpatient,,,891.95,535.17,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,624.37,70,,,percent of total billed charges,70% of total billed charges,668.96,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,713.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,682.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,153.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,401.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,624.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,535.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,624.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,428.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,802.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,139.77,1043.05,
Blood test to assist with diagnosis,4066000,CDM,312,RC,88312,HCPCS,Outpatient,,,222.75,133.65,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.02,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.93,70,,,percent of total billed charges,70% of total billed charges,167.06,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,170.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,106.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,200.48,
Blood test to assist with diagnosis,4066009,CDM,312,RC,88313,HCPCS,Outpatient,,,203.5,122.1,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,142.45,70,,,percent of total billed charges,70% of total billed charges,152.63,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,162.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,155.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,91.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,97.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,183.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5.7,183.15,
CENTEX STAIN PERPARATION,4066061,CDM,312,RC,,,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175,50,,,percent of total billed charges,pays at 50% of total billed charges,245,70,,,percent of total billed charges,70% of total billed charges,262.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.85,315,
CYTOPATHOLOGY WASH BRUSH,4066072,CDM,311,RC,88104,HCPCS,Outpatient,,,96.5,57.9,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,67.55,70,,,percent of total billed charges,70% of total billed charges,72.38,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,73.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,43.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,67.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,46.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,86.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,109.29,
"CYTOPAHTOLOGY FLUID,CONC",4068108,CDM,311,RC,88108,HCPCS,Outpatient,,,156.2,93.72,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,109.34,70,,,percent of total billed charges,70% of total billed charges,117.15,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,119.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,109.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,74.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,140.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,25.07,140.58,
Urine test,4068112,CDM,311,RC,88112,HCPCS,Outpatient,,,134,80.4,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges,100.5,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,102.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,64.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,120.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,57.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,161.36,
PAP smear,4068142,CDM,311,RC,88142,HCPCS,Outpatient,,,136.26,81.76,,71.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,95.38,70,,,percent of total billed charges,70% of total billed charges,102.2,75,,,percent of total billed charges,75% of total billed charges,36.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.91,350,,,Fee Schedule,350% of CMS OPPS Rate,20.66,102,,,Fee Schedule,102% of CMS OPPS Rate,104.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,61.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,22.51,100,,,Fee Schedule,100% of UHC Fee Schedule,95.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,46.59,230,,,Fee Schedule,230% of CMS OPPS Rate,65.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,122.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of CMS OPPS Rate,15.87,122.63,
"CYTOLOGY SMEAR,OTHER",4068170,CDM,311,RC,88160,HCPCS,Outpatient,,,78,46.8,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.6,70,,,percent of total billed charges,70% of total billed charges,58.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,59.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,35.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,54.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,37.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,80.32,
ASPIRATE-FINE NEEDLE EVAL,4068172,CDM,311,RC,88172,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,18.51,506.06,
ASPIRATE-F.N. INTERP/RPT,4068173,CDM,311,RC,88173,HCPCS,Outpatient,,,148.5,89.1,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,103.95,70,,,percent of total billed charges,70% of total billed charges,111.38,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,118.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,113.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,103.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,103.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,133.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,37.04,161.36,
PAP smear,4068175,CDM,311,RC,88175,HCPCS,Outpatient,,,166,99.6,,94.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,116.2,70,,,percent of total billed charges,70% of total billed charges,124.5,75,,,percent of total billed charges,75% of total billed charges,47.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.13,350,,,Fee Schedule,350% of CMS OPPS Rate,27.14,102,,,Fee Schedule,102% of CMS OPPS Rate,126.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,29.44,100,,,Fee Schedule,100% of UHC Fee Schedule,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,61.2,230,,,Fee Schedule,230% of CMS OPPS Rate,79.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,149.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,100,,,Fee Schedule,100% of CMS OPPS Rate,25.59,149.4,
"SURG/PATH, GROSS ONLY",4068300,CDM,312,RC,88300,HCPCS,Outpatient,,,115.5,69.3,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,10.53,103.95,
SURG/PATH GR & MICRO II,4068302,CDM,312,RC,88302,HCPCS,Outpatient,,,142.65,85.59,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges,106.99,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,109.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,64.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,68.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,128.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,128.39,
SURG/PATH GR & MICRO III,4068304,CDM,312,RC,88304,HCPCS,Outpatient,,,213.95,128.37,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.77,70,,,percent of total billed charges,70% of total billed charges,160.46,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,171.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,163.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,96.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,149.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,102.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,192.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,192.56,
Test of tissues for diagnosis of abnormalities,4068305,CDM,312,RC,88305,HCPCS,Outpatient,,,232.1,139.26,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,162.47,70,,,percent of total billed charges,70% of total billed charges,174.08,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,185.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,177.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,162.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,111.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,208.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,208.89,
SURG/PATH GR & MICRO V,4068307,CDM,312,RC,88307,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,70.7,1043.05,
SURG/PATH GR & MICRO VI,4068309,CDM,312,RC,88309,HCPCS,Outpatient,,,1700,1020,,2498.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1102.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1190,70,,,percent of total billed charges,70% of total billed charges,1275,75,,,percent of total billed charges,75% of total billed charges,1270.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.73,350,,,Fee Schedule,350% of CMS OPPS Rate,720.04,103,,,Fee Schedule,103% of CMS OPPS Rate,1300.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,765,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1020,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,486.86,100,,,Fee Schedule,100% of UHC Fee Schedule,1190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.62,100,,,Fee Schedule,100% of CMS OPPS Rate,816,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1530,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,70.7,2498.97,
DECALCIFICATION OF BONE,4068311,CDM,312,RC,88311,HCPCS,Outpatient,,,194.85,116.91,,35.07,18,,,percent of total billed charges,pays at 18% of total charges,5.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.4,70,,,percent of total billed charges,70% of total billed charges,146.14,75,,,percent of total billed charges,75% of total billed charges,97.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,136.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.42,100,,,Fee Schedule,100% of UHC Fee Schedule,136.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,194.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.7,194.85,
"FROZEN SECTION, INITIAL",4068331,CDM,312,RC,88331,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,42.47,506.06,
"FROZEN SECTION, EA ADD'L",4068332,CDM,312,RC,88332,HCPCS,Outpatient,,,87.12,52.27,,15.68,18,,,percent of total billed charges,pays at 18% of total charges,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,70,,,percent of total billed charges,70% of total billed charges,65.34,75,,,percent of total billed charges,75% of total billed charges,43.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,69.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.44,100,,,Fee Schedule,100% of UHC Fee Schedule,60.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.15,87.12,
"CYTOLOGY EXAM, TOUCH PREP INITIAL",4068333,CDM,311,RC,88333,HCPCS,Outpatient,,,1700,1020,,2498.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1102.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1190,70,,,percent of total billed charges,70% of total billed charges,1275,75,,,percent of total billed charges,75% of total billed charges,1270.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.73,350,,,Fee Schedule,350% of CMS OPPS Rate,720.04,103,,,Fee Schedule,103% of CMS OPPS Rate,1300.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,292.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,765,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1020,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,486.86,100,,,Fee Schedule,100% of UHC Fee Schedule,1190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.62,100,,,Fee Schedule,100% of CMS OPPS Rate,816,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1530,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,266.39,2498.97,
"CYTOLOGY EXAM, TOUCH PREP ADD",4068334,CDM,311,RC,88334,HCPCS,Outpatient,,,75.1,45.06,,13.52,18,,,percent of total billed charges,pays at 18% of total charges,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.57,70,,,percent of total billed charges,70% of total billed charges,56.33,75,,,percent of total billed charges,75% of total billed charges,37.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.58,100,,,Fee Schedule,100% of UHC Fee Schedule,52.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,75.1,
IMMHIST STAIN EA  ADDTL AB,4068341,CDM,312,RC,88341,HCPCS,Outpatient,,,223.5,134.1,,40.23,18,,,percent of total billed charges,pays at 18% of total charges,59.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.45,70,,,percent of total billed charges,70% of total billed charges,167.63,75,,,percent of total billed charges,75% of total billed charges,111.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.32,100,,,Fee Schedule,100% of UHC Fee Schedule,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,59.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.23,223.5,
IMMHIST STAIN MULTIPLE AB PER SLIDE,4068344,CDM,312,RC,88344,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,103.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,103.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,103.69,1043.05,
Pathology test,4068415,CDM,312,RC,88342,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,49.84,506.06,
Test of a wound for type of bacterial infection,4070002,CDM,306,RC,87077,HCPCS,Outpatient,,,37.8,22.68,,28.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,26.46,70,,,percent of total billed charges,70% of total billed charges,28.35,75,,,percent of total billed charges,75% of total billed charges,14.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,30.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.28,350,,,Fee Schedule,350% of CMS OPPS Rate,8.24,102,,,Fee Schedule,102% of CMS OPPS Rate,28.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,17.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.97,100,,,Fee Schedule,100% of UHC Fee Schedule,26.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,18.58,230,,,Fee Schedule,230% of CMS OPPS Rate,18.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,34.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,34.02,
"ANAEROBIC ISOLATE,ADD ID",4070003,CDM,306,RC,87076,HCPCS,Outpatient,,,86.85,52.11,,28.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges,65.14,75,,,percent of total billed charges,75% of total billed charges,14.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.28,350,,,Fee Schedule,350% of CMS OPPS Rate,8.24,102,,,Fee Schedule,102% of CMS OPPS Rate,66.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.97,100,,,Fee Schedule,100% of UHC Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,18.58,230,,,Fee Schedule,230% of CMS OPPS Rate,41.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,100,,,Fee Schedule,100% of CMS OPPS Rate,8.08,78.17,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,4071205,CDM,306,RC,87205,HCPCS,Outpatient,,,86.85,52.11,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges,65.14,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,66.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,41.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,78.17,
A lab test to screen for evidence of vaginal infection,4071210,CDM,306,RC,87210,HCPCS,Outpatient,,,67.1,40.26,,20.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.97,70,,,percent of total billed charges,70% of total billed charges,50.33,75,,,percent of total billed charges,75% of total billed charges,10.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.37,350,,,Fee Schedule,350% of CMS OPPS Rate,5.93,102,,,Fee Schedule,102% of CMS OPPS Rate,51.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of UHC Fee Schedule,46.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.38,230,,,Fee Schedule,230% of CMS OPPS Rate,32.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,60.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,60.39,
"OCCULT BLOOD SCREENING, FECES",4071244,CDM,301,RC,82270,HCPCS,Outpatient,,,29.25,17.55,,15.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges,21.94,75,,,percent of total billed charges,75% of total billed charges,7.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.33,350,,,Fee Schedule,350% of CMS OPPS Rate,4.46,102,,,Fee Schedule,102% of CMS OPPS Rate,22.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,13.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of UHC Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,10.07,230,,,Fee Schedule,230% of CMS OPPS Rate,14.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,3.23,26.33,
"OCCULT BLD DIAGNOSTIC, FECES",4071272,CDM,301,RC,82272,HCPCS,Outpatient,,,29.25,17.55,,14.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges,21.94,75,,,percent of total billed charges,75% of total billed charges,7.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,350,,,Fee Schedule,350% of CMS OPPS Rate,4.31,102,,,Fee Schedule,102% of CMS OPPS Rate,22.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,13.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,100,,,Fee Schedule,100% of UHC Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,230,,,Fee Schedule,230% of CMS OPPS Rate,14.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,26.33,
Flu test,4071804,CDM,306,RC,87804,HCPCS,Outpatient,,,171,102.6,,58.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,119.7,70,,,percent of total billed charges,70% of total billed charges,128.25,75,,,percent of total billed charges,75% of total billed charges,29.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.92,350,,,Fee Schedule,350% of CMS OPPS Rate,16.88,102,,,Fee Schedule,102% of CMS OPPS Rate,130.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,76.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of UHC Fee Schedule,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,38.06,230,,,Fee Schedule,230% of CMS OPPS Rate,82.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,153.9,
Test for strep A,4071880,CDM,306,RC,87880,HCPCS,Outpatient,,,108.24,64.94,,58.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges,81.18,75,,,percent of total billed charges,75% of total billed charges,29.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.85,350,,,Fee Schedule,350% of CMS OPPS Rate,16.86,102,,,Fee Schedule,102% of CMS OPPS Rate,82.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,48.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,38.01,230,,,Fee Schedule,230% of CMS OPPS Rate,51.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,97.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,97.42,
Medical test to find an infection,4071975,CDM,306,RC,87081,HCPCS,Outpatient,,,219.15,131.49,,23.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.63,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,153.41,70,,,percent of total billed charges,70% of total billed charges,164.36,75,,,percent of total billed charges,75% of total billed charges,11.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,175.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,350,,,Fee Schedule,350% of CMS OPPS Rate,6.76,102,,,Fee Schedule,102% of CMS OPPS Rate,167.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,7.36,100,,,Fee Schedule,100% of UHC Fee Schedule,153.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15.24,230,,,Fee Schedule,230% of CMS OPPS Rate,105.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,197.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,197.24,
"OCCULT BLD DIAGNOSTIC, FECES",4072272,CDM,301,RC,82272,HCPCS,Outpatient,,,29.25,17.55,,14.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges,21.94,75,,,percent of total billed charges,75% of total billed charges,7.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,350,,,Fee Schedule,350% of CMS OPPS Rate,4.31,102,,,Fee Schedule,102% of CMS OPPS Rate,22.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,13.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,100,,,Fee Schedule,100% of UHC Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,230,,,Fee Schedule,230% of CMS OPPS Rate,14.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3.81,26.33,
STREPTOZYME TITER,4076061,CDM,302,RC,86060,HCPCS,Outpatient,,,66.15,39.69,,25.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,13.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.55,350,,,Fee Schedule,350% of CMS OPPS Rate,7.44,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,8.11,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.79,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7.3,59.54,
STREPTOZYME SCREEN,4076062,CDM,302,RC,86063,HCPCS,Outpatient,,,63.8,38.28,,20.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.66,70,,,percent of total billed charges,70% of total billed charges,47.85,75,,,percent of total billed charges,75% of total billed charges,10.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.19,350,,,Fee Schedule,350% of CMS OPPS Rate,5.88,102,,,Fee Schedule,102% of CMS OPPS Rate,48.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,28.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6.41,100,,,Fee Schedule,100% of UHC Fee Schedule,44.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,230,,,Fee Schedule,230% of CMS OPPS Rate,30.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,57.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5.77,57.42,
PPD TB INTRADERMAL TEST,4076580,CDM,302,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
HIV-1 STAT SCREEN,4076701,CDM,302,RC,86701,HCPCS,Outpatient,,,123.75,74.25,,31.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.89,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges,92.81,75,,,percent of total billed charges,75% of total billed charges,16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.11,350,,,Fee Schedule,350% of CMS OPPS Rate,9.06,102,,,Fee Schedule,102% of CMS OPPS Rate,94.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.87,100,,,Fee Schedule,100% of UHC Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,230,,,Fee Schedule,230% of CMS OPPS Rate,59.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,111.38,
CULTURE BACTERIAL QUANT,4076910,CDM,306,RC,87071,HCPCS,Outpatient,,,173.7,104.22,,35.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges,130.28,75,,,percent of total billed charges,75% of total billed charges,17.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,350,,,Fee Schedule,350% of CMS OPPS Rate,10.08,102,,,Fee Schedule,102% of CMS OPPS Rate,132.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,100,,,Fee Schedule,100% of UHC Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,22.74,230,,,Fee Schedule,230% of CMS OPPS Rate,83.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,156.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,7.14,156.33,
Culture of the urine to determine number of bacteria,4076920,CDM,306,RC,87086,HCPCS,Outpatient,,,135,81,,28.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,14.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.24,350,,,Fee Schedule,350% of CMS OPPS Rate,8.23,102,,,Fee Schedule,102% of CMS OPPS Rate,103.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.96,100,,,Fee Schedule,100% of UHC Fee Schedule,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,230,,,Fee Schedule,230% of CMS OPPS Rate,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,121.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,121.5,
Test of body fluid other than blood to assess for bacteria,4076940,CDM,306,RC,87070,HCPCS,Outpatient,,,222.3,133.38,,30.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges,166.73,75,,,percent of total billed charges,75% of total billed charges,15.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.16,350,,,Fee Schedule,350% of CMS OPPS Rate,8.79,102,,,Fee Schedule,102% of CMS OPPS Rate,170.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,100.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of UHC Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.82,230,,,Fee Schedule,230% of CMS OPPS Rate,106.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,200.07,
Medical test to find an infection,4076975,CDM,306,RC,87081,HCPCS,Outpatient,,,219.15,131.49,,23.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.63,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,153.41,70,,,percent of total billed charges,70% of total billed charges,164.36,75,,,percent of total billed charges,75% of total billed charges,11.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,175.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.2,350,,,Fee Schedule,350% of CMS OPPS Rate,6.76,102,,,Fee Schedule,102% of CMS OPPS Rate,167.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,7.36,100,,,Fee Schedule,100% of UHC Fee Schedule,153.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15.24,230,,,Fee Schedule,230% of CMS OPPS Rate,105.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,197.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6.63,197.24,
"CULTURE/SEN, STOOL",4077000,CDM,306,RC,87045,HCPCS,Outpatient,,,173.7,104.22,,33.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges,130.28,75,,,percent of total billed charges,75% of total billed charges,16.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.04,350,,,Fee Schedule,350% of CMS OPPS Rate,9.62,102,,,Fee Schedule,102% of CMS OPPS Rate,132.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,100,,,Fee Schedule,100% of UHC Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,230,,,Fee Schedule,230% of CMS OPPS Rate,83.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,156.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,156.33,
ANAEROB BACT CULTURE W ID,4077006,CDM,306,RC,87075,HCPCS,Outpatient,,,54.9,32.94,,33.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,17.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.14,350,,,Fee Schedule,350% of CMS OPPS Rate,9.65,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,49.41,
Test of body fluid other than blood to assess for bacteria,4077006,CDM,306,RC,87070,HCPCS,Outpatient,,,222.3,133.38,,30.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges,166.73,75,,,percent of total billed charges,75% of total billed charges,15.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.16,350,,,Fee Schedule,350% of CMS OPPS Rate,8.79,102,,,Fee Schedule,102% of CMS OPPS Rate,170.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,100.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of UHC Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.82,230,,,Fee Schedule,230% of CMS OPPS Rate,106.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,200.07,
CULTURE BACTERIAL QUANT,4077007,CDM,306,RC,87071,HCPCS,Outpatient,,,173.7,104.22,,35.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges,130.28,75,,,percent of total billed charges,75% of total billed charges,17.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,350,,,Fee Schedule,350% of CMS OPPS Rate,10.08,102,,,Fee Schedule,102% of CMS OPPS Rate,132.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,100,,,Fee Schedule,100% of UHC Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,22.74,230,,,Fee Schedule,230% of CMS OPPS Rate,83.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,156.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,7.14,156.33,
ANAEROB BACT CULTURE W ID,4077007,CDM,306,RC,87075,HCPCS,Outpatient,,,54.9,32.94,,33.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,17.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.14,350,,,Fee Schedule,350% of CMS OPPS Rate,9.65,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,49.41,
ANAEROB BACT CULTURE W ID,4077008,CDM,306,RC,87075,HCPCS,Outpatient,,,54.9,32.94,,33.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,17.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.14,350,,,Fee Schedule,350% of CMS OPPS Rate,9.65,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,49.41,
Test of body fluid other than blood to assess for bacteria,4077008,CDM,306,RC,87070,HCPCS,Outpatient,,,222.3,133.38,,30.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges,166.73,75,,,percent of total billed charges,75% of total billed charges,15.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.16,350,,,Fee Schedule,350% of CMS OPPS Rate,8.79,102,,,Fee Schedule,102% of CMS OPPS Rate,170.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,100.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of UHC Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.82,230,,,Fee Schedule,230% of CMS OPPS Rate,106.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,200.07,
ANAEROB BACT CULTURE W ID,4077009,CDM,306,RC,87075,HCPCS,Outpatient,,,54.9,32.94,,33.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,17.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.14,350,,,Fee Schedule,350% of CMS OPPS Rate,9.65,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,49.41,
Test of body fluid other than blood to assess for bacteria,4077009,CDM,306,RC,87070,HCPCS,Outpatient,,,222.3,133.38,,30.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges,166.73,75,,,percent of total billed charges,75% of total billed charges,15.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.16,350,,,Fee Schedule,350% of CMS OPPS Rate,8.79,102,,,Fee Schedule,102% of CMS OPPS Rate,170.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,100.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of UHC Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.82,230,,,Fee Schedule,230% of CMS OPPS Rate,106.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,200.07,
CHLAMYDIA PNEUM PROBE,4077011,CDM,300,RC,87486,HCPCS,Outpatient,,,239,143.4,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,215.1,
INFECTIOUS AGENT BY DNA PNEUMOPHILA,4077011,CDM,306,RC,87541,HCPCS,Outpatient,,,230.72,138.43,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,161.5,70,,,percent of total billed charges,70% of total billed charges,173.04,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,184.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,176.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,103.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,161.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,110.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,207.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,207.65,
RESPIRATORY VIRUS BY DNA/RNA,4077011,CDM,306,RC,87632,HCPCS,Outpatient,,,546,327.6,,771.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,537.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,382.2,70,,,percent of total billed charges,70% of total billed charges,409.5,75,,,percent of total billed charges,75% of total billed charges,392.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,436.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.21,350,,,Fee Schedule,350% of CMS OPPS Rate,222.42,102,,,Fee Schedule,102% of CMS OPPS Rate,417.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,245.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,382.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,327.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,501.53,230,,,Fee Schedule,230% of CMS OPPS Rate,262.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,491.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,85.56,771.93,
MYCOPLASMA PNEUMONIAE BY DNA/RNA,4077011,CDM,306,RC,87581,HCPCS,Outpatient,,,176,105.6,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges,132,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,134.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,84.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,158.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,158.4,
BACTERIAL DETECTION PROBE,4077011,CDM,300,RC,87798,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
Test of body fluid other than blood to assess for bacteria,4077013,CDM,306,RC,87070,HCPCS,Outpatient,,,222.3,133.38,,30.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges,166.73,75,,,percent of total billed charges,75% of total billed charges,15.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,177.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.16,350,,,Fee Schedule,350% of CMS OPPS Rate,8.79,102,,,Fee Schedule,102% of CMS OPPS Rate,170.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,100.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of UHC Fee Schedule,155.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.82,230,,,Fee Schedule,230% of CMS OPPS Rate,106.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,200.07,
ANAEROB BACT CULTURE W ID,4077013,CDM,306,RC,87075,HCPCS,Outpatient,,,54.9,32.94,,33.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,17.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.14,350,,,Fee Schedule,350% of CMS OPPS Rate,9.65,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,49.41,
Flu test,4077014,CDM,306,RC,87804,HCPCS,Outpatient,,,50,30,,58.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,29.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.92,350,,,Fee Schedule,350% of CMS OPPS Rate,16.88,102,,,Fee Schedule,102% of CMS OPPS Rate,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of UHC Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,38.06,230,,,Fee Schedule,230% of CMS OPPS Rate,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,58.58,
ENTEROVIRUS DNA AMP PROBE,4077016,CDM,306,RC,87498,HCPCS,Outpatient,,,323.1,193.86,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,226.17,70,,,percent of total billed charges,70% of total billed charges,242.33,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,258.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,247.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,145.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,226.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,155.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,290.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,290.79,
HERPES SIMPLEX DNA PROBE,4077016,CDM,300,RC,87529,HCPCS,Outpatient,,,242.55,145.53,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,169.79,70,,,percent of total billed charges,70% of total billed charges,181.91,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,194.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,185.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,169.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,116.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,218.3,
CMV DNA DETECTOR,4077016,CDM,300,RC,87496,HCPCS,Outpatient,,,227.7,136.62,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,159.39,70,,,percent of total billed charges,70% of total billed charges,170.78,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,182.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,174.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,159.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,109.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,204.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,204.93,
INFECTIOUS AGENT BY DNA HPV6,4077016,CDM,300,RC,87532,HCPCS,Outpatient,,,238.8,143.28,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges,179.1,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,214.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,214.92,
Blood test for strep infection,4077016,CDM,306,RC,87653,HCPCS,Outpatient,,,239,143.4,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,215.1,
BACTERIAL DETECTION PROBE,4077016,CDM,300,RC,87798,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
CHLAMYDIA PNEUM PROBE,4077017,CDM,300,RC,87486,HCPCS,Outpatient,,,239,143.4,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,215.1,
BACTERIAL DETECTION PROBE,4077017,CDM,300,RC,87798,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
MYCOPLASMA PNEUM PROB,4077017,CDM,300,RC,87501,HCPCS,Outpatient,,,154,92.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,129.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,107.8,70,,,percent of total billed charges,70% of total billed charges,115.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,117.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,69.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,57.02,100,,,Fee Schedule,100% of UHC Fee Schedule,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,73.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,181.63,
INFECTIOUS AGENT BY DNA RESP VIRUS,4077017,CDM,300,RC,87633,HCPCS,Outpatient,,,1250,750,,1475.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1049.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,875,70,,,percent of total billed charges,70% of total billed charges,937.5,75,,,percent of total billed charges,75% of total billed charges,750.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1458.73,350,,,Fee Schedule,350% of CMS OPPS Rate,425.11,102,,,Fee Schedule,102% of CMS OPPS Rate,956.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,215.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,562.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,875,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,958.59,230,,,Fee Schedule,230% of CMS OPPS Rate,600,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1125,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,195.88,1475.4,
CULTURE TYPING ID BY DNA PROBE,4077018,CDM,300,RC,87150,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
CHLAMYDIA PNEUM PROBE,4077019,CDM,300,RC,87486,HCPCS,Outpatient,,,239,143.4,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,215.1,
INFECT AGT BY DNA SAR RESP PATH,4077019,CDM,310,RC,87637,HCPCS,Outpatient,,,714,428.4,,504.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,106.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,357,50,,,percent of total billed charges,pays at 50% of total billed charges,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,256.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,499.2,350,,,Fee Schedule,350% of CMS OPPS Rate,145.48,102,,,Fee Schedule,102% of CMS OPPS Rate,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,357,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,328.04,230,,,Fee Schedule,230% of CMS OPPS Rate,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,106.97,642.6,
BACTERIAL DETECTION PROBE,4077019,CDM,300,RC,87798,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
MYCOPLASMA PNEUM PROB,4077019,CDM,300,RC,87501,HCPCS,Outpatient,,,154,92.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,129.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,107.8,70,,,percent of total billed charges,70% of total billed charges,115.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,117.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,69.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,57.02,100,,,Fee Schedule,100% of UHC Fee Schedule,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,73.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,181.63,
"CONCENTRATION,MICRO",4077021,CDM,306,RC,87015,HCPCS,Outpatient,,,48.15,28.89,,23.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges,36.11,75,,,percent of total billed charges,75% of total billed charges,12.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.38,350,,,Fee Schedule,350% of CMS OPPS Rate,6.81,102,,,Fee Schedule,102% of CMS OPPS Rate,36.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of UHC Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,230,,,Fee Schedule,230% of CMS OPPS Rate,23.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,43.34,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,4077022,CDM,306,RC,87046,HCPCS,Outpatient,,,28,16.8,,33.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.04,350,,,Fee Schedule,350% of CMS OPPS Rate,9.62,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,10.49,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,21.71,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.44,100,,,Fee Schedule,100% of CMS OPPS Rate,3.56,33.41,
Blood test to screen for bacteria in the blood,4077040,CDM,306,RC,87040,HCPCS,Outpatient,,,279.9,167.94,,36.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.93,70,,,percent of total billed charges,70% of total billed charges,209.93,75,,,percent of total billed charges,75% of total billed charges,18.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,223.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.12,350,,,Fee Schedule,350% of CMS OPPS Rate,10.52,102,,,Fee Schedule,102% of CMS OPPS Rate,214.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,125.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,195.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of UHC Fee Schedule,195.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,230,,,Fee Schedule,230% of CMS OPPS Rate,134.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,251.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,251.91,
A test used to determine which medications work on bacteria for fungi,4077043,CDM,306,RC,87186,HCPCS,Outpatient,,,157.95,94.77,,30.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges,118.46,75,,,percent of total billed charges,75% of total billed charges,15.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.27,350,,,Fee Schedule,350% of CMS OPPS Rate,8.82,102,,,Fee Schedule,102% of CMS OPPS Rate,120.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,9.6,100,,,Fee Schedule,100% of UHC Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,230,,,Fee Schedule,230% of CMS OPPS Rate,75.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,142.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,142.16,
SENSITIVITY DISK PER PLAT,4077048,CDM,306,RC,87184,HCPCS,Outpatient,,,123.75,74.25,,26.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges,92.81,75,,,percent of total billed charges,75% of total billed charges,13.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.18,350,,,Fee Schedule,350% of CMS OPPS Rate,7.62,102,,,Fee Schedule,102% of CMS OPPS Rate,94.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.66,100,,,Fee Schedule,100% of UHC Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,230,,,Fee Schedule,230% of CMS OPPS Rate,59.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.48,111.38,
"SUSCEPTIBILITY,AGAR DIL",4077051,CDM,306,RC,87181,HCPCS,Outpatient,,,137.5,82.5,,16.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.25,70,,,percent of total billed charges,70% of total billed charges,103.13,75,,,percent of total billed charges,75% of total billed charges,8.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.62,350,,,Fee Schedule,350% of CMS OPPS Rate,4.84,102,,,Fee Schedule,102% of CMS OPPS Rate,105.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,61.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,96.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10.92,230,,,Fee Schedule,230% of CMS OPPS Rate,66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,123.75,
"SUSCEPTIBILITY,ENZYME",4077052,CDM,306,RC,87185,HCPCS,Outpatient,,,37.8,22.68,,16.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,26.46,70,,,percent of total billed charges,70% of total billed charges,28.35,75,,,percent of total billed charges,75% of total billed charges,8.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,30.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.62,350,,,Fee Schedule,350% of CMS OPPS Rate,4.84,102,,,Fee Schedule,102% of CMS OPPS Rate,28.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,17.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,26.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10.92,230,,,Fee Schedule,230% of CMS OPPS Rate,18.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,34.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4.75,34.02,
"CULTURE,TYPING AGGL ID",4077053,CDM,306,RC,87147,HCPCS,Outpatient,,,69.75,41.85,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.04,62.78,
ANAEROB BACT CULTURE W ID,4077075,CDM,306,RC,87075,HCPCS,Outpatient,,,54.9,32.94,,33.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,17.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.14,350,,,Fee Schedule,350% of CMS OPPS Rate,9.65,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,10.52,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,100,,,Fee Schedule,100% of CMS OPPS Rate,9.47,49.41,
Culture of the urine to determine bacterial infection,4077088,CDM,300,RC,87088,HCPCS,Outpatient,,,48.15,28.89,,28.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges,36.11,75,,,percent of total billed charges,75% of total billed charges,14.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.31,350,,,Fee Schedule,350% of CMS OPPS Rate,8.25,102,,,Fee Schedule,102% of CMS OPPS Rate,36.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of UHC Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,18.6,230,,,Fee Schedule,230% of CMS OPPS Rate,23.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,100,,,Fee Schedule,100% of CMS OPPS Rate,8.09,43.34,
CULTURE-FUNGUS-MISC-SPEC,4077101,CDM,306,RC,87102,HCPCS,Outpatient,,,100.35,60.21,,29.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70.25,70,,,percent of total billed charges,70% of total billed charges,75.26,75,,,percent of total billed charges,75% of total billed charges,15.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.43,350,,,Fee Schedule,350% of CMS OPPS Rate,8.57,102,,,Fee Schedule,102% of CMS OPPS Rate,76.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,45.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,9.34,100,,,Fee Schedule,100% of UHC Fee Schedule,70.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,19.34,230,,,Fee Schedule,230% of CMS OPPS Rate,48.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,90.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8.41,90.32,
"CULTURE,FUNGAL/BLOOD",4077103,CDM,306,RC,87103,HCPCS,Outpatient,,,279.9,167.94,,72.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.93,70,,,percent of total billed charges,70% of total billed charges,209.93,75,,,percent of total billed charges,75% of total billed charges,36.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,223.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.61,350,,,Fee Schedule,350% of CMS OPPS Rate,20.86,102,,,Fee Schedule,102% of CMS OPPS Rate,214.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,125.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,195.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,18.41,100,,,Fee Schedule,100% of UHC Fee Schedule,195.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,47.05,230,,,Fee Schedule,230% of CMS OPPS Rate,134.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,251.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20.46,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,251.91,
"FUNGAL ID, YEAST",4077106,CDM,300,RC,87106,HCPCS,Outpatient,,,47.25,28.35,,36.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,18.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.12,350,,,Fee Schedule,350% of CMS OPPS Rate,10.52,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,42.53,
"FUNGAL ID, MOLD",4077107,CDM,306,RC,87107,HCPCS,Outpatient,,,47.25,28.35,,36.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges,35.44,75,,,percent of total billed charges,75% of total billed charges,18.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.12,350,,,Fee Schedule,350% of CMS OPPS Rate,10.52,102,,,Fee Schedule,102% of CMS OPPS Rate,36.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of UHC Fee Schedule,33.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,230,,,Fee Schedule,230% of CMS OPPS Rate,22.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,100,,,Fee Schedule,100% of CMS OPPS Rate,10.32,42.53,
CULTURE TYPING ID BY DNA PROBE,4077150,CDM,300,RC,87150,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
A test of the stool to diagnose Clostridium difficile (C. diff) infection,4077174,CDM,306,RC,87324,HCPCS,Outpatient,,,91.8,55.08,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.26,70,,,percent of total billed charges,70% of total billed charges,68.85,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,70.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,41.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,64.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,44.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,82.62,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,4077205,CDM,306,RC,87205,HCPCS,Outpatient,,,86.85,52.11,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges,65.14,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,66.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,41.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,78.17,
AFB SMEAR-MISC SPEC,4077206,CDM,306,RC,87206,HCPCS,Outpatient,,,54.9,32.94,,19.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,9.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.86,350,,,Fee Schedule,350% of CMS OPPS Rate,5.49,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,49.41,
A lab test to screen for evidence of vaginal infection,4077210,CDM,306,RC,87210,HCPCS,Outpatient,,,67.1,40.26,,20.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.97,70,,,percent of total billed charges,70% of total billed charges,50.33,75,,,percent of total billed charges,75% of total billed charges,10.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.37,350,,,Fee Schedule,350% of CMS OPPS Rate,5.93,102,,,Fee Schedule,102% of CMS OPPS Rate,51.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of UHC Fee Schedule,46.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.38,230,,,Fee Schedule,230% of CMS OPPS Rate,32.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,60.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,60.39,
FUNGUS DIR PREP-MISC SPEC,4077220,CDM,306,RC,87220,HCPCS,Outpatient,,,61.65,36.99,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.16,70,,,percent of total billed charges,70% of total billed charges,46.24,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,47.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,27.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,43.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,29.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,55.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,55.49,
PINWORM SLIDE,4077221,CDM,306,RC,87172,HCPCS,Outpatient,,,69.75,41.85,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,62.78,
"FAT, QUALITATIVE, STOOL",4077225,CDM,301,RC,82705,HCPCS,Outpatient,,,107.55,64.53,,18.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.1,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.29,70,,,percent of total billed charges,70% of total billed charges,80.66,75,,,percent of total billed charges,75% of total billed charges,9.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.84,350,,,Fee Schedule,350% of CMS OPPS Rate,5.2,102,,,Fee Schedule,102% of CMS OPPS Rate,82.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,48.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.66,100,,,Fee Schedule,100% of UHC Fee Schedule,75.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,11.73,230,,,Fee Schedule,230% of CMS OPPS Rate,51.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,96.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,5.09,96.8,
"LEUKOCYTES, STOOL",4077240,CDM,309,RC,89055,HCPCS,Outpatient,,,75.6,45.36,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.92,70,,,percent of total billed charges,70% of total billed charges,56.7,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,57.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,34.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,52.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,36.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,68.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,68.04,
"OCCULT BLOOD SCREENING, FECES",4077244,CDM,301,RC,82270,HCPCS,Outpatient,,,29.25,17.55,,15.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges,21.94,75,,,percent of total billed charges,75% of total billed charges,7.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,23.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.33,350,,,Fee Schedule,350% of CMS OPPS Rate,4.46,102,,,Fee Schedule,102% of CMS OPPS Rate,22.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,13.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of UHC Fee Schedule,20.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,10.07,230,,,Fee Schedule,230% of CMS OPPS Rate,14.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,3.23,26.33,
OCCULT BLOOD GASTRIC,4077246,CDM,301,RC,82271,HCPCS,Outpatient,,,55.8,33.48,,18.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.06,70,,,percent of total billed charges,70% of total billed charges,41.85,75,,,percent of total billed charges,75% of total billed charges,9.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.62,350,,,Fee Schedule,350% of CMS OPPS Rate,5.42,102,,,Fee Schedule,102% of CMS OPPS Rate,42.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,25.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,4.79,100,,,Fee Schedule,100% of UHC Fee Schedule,39.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,12.23,230,,,Fee Schedule,230% of CMS OPPS Rate,26.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,50.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,5.32,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,50.22,
Blood test to if peptic ulcers are caused by a certain bacterium,4077248,CDM,302,RC,86677,HCPCS,Outpatient,,,55.55,33.33,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,41.66,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,42.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.12,100,,,Fee Schedule,100% of UHC Fee Schedule,38.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,26.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,50,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,59.64,
RESP SYNCYTIAL AG IA,4077500,CDM,300,RC,87420,HCPCS,Outpatient,,,342.9,205.74,,49.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.91,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,240.03,70,,,percent of total billed charges,70% of total billed charges,257.18,75,,,percent of total billed charges,75% of total billed charges,25.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,274.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.68,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,262.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,154.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,240.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,240.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,31.99,230,,,Fee Schedule,230% of CMS OPPS Rate,164.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,308.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,308.61,
MYCOPLASMA PNEUMONIAE BY DNA/RNA,4077581,CDM,306,RC,87581,HCPCS,Outpatient,,,176,105.6,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges,132,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,134.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,84.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,158.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,158.4,
RESPIRATORY VIRUS BY DNA/RNA,4077632,CDM,306,RC,87632,HCPCS,Outpatient,,,546,327.6,,771.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,537.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,382.2,70,,,percent of total billed charges,70% of total billed charges,409.5,75,,,percent of total billed charges,75% of total billed charges,392.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,436.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.21,350,,,Fee Schedule,350% of CMS OPPS Rate,222.42,102,,,Fee Schedule,102% of CMS OPPS Rate,417.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,245.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,382.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,327.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,501.53,230,,,Fee Schedule,230% of CMS OPPS Rate,262.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,491.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,218.06,100,,,Fee Schedule,100% of CMS OPPS Rate,85.56,771.93,
INFECT AGT BY DNA SAR RESP PATH,4077637,CDM,310,RC,87637,HCPCS,Outpatient,,,714,428.4,,504.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,106.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,357,50,,,percent of total billed charges,pays at 50% of total billed charges,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,256.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,499.2,350,,,Fee Schedule,350% of CMS OPPS Rate,145.48,102,,,Fee Schedule,102% of CMS OPPS Rate,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,357,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,328.04,230,,,Fee Schedule,230% of CMS OPPS Rate,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,142.63,100,,,Fee Schedule,100% of CMS OPPS Rate,106.97,642.6,
Flu test,4077804,CDM,306,RC,87804,HCPCS,Outpatient,,,50,30,,58.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,29.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.92,350,,,Fee Schedule,350% of CMS OPPS Rate,16.88,102,,,Fee Schedule,102% of CMS OPPS Rate,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of UHC Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,38.06,230,,,Fee Schedule,230% of CMS OPPS Rate,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,58.58,
INFECTIOUS AGENT HIV 1 AG HIV 1/2 AB,4077806,CDM,306,RC,87806,HCPCS,Outpatient,,,153,91.8,,116,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,32.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,107.1,70,,,percent of total billed charges,70% of total billed charges,114.75,75,,,percent of total billed charges,75% of total billed charges,58.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,122.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.69,350,,,Fee Schedule,350% of CMS OPPS Rate,33.42,102,,,Fee Schedule,102% of CMS OPPS Rate,117.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,68.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,29.49,100,,,Fee Schedule,100% of UHC Fee Schedule,107.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,75.37,230,,,Fee Schedule,230% of CMS OPPS Rate,73.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,137.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,29.49,137.7,
REDUCING SUBSTANCES(STOOL,4080022,CDM,301,RC,84376,HCPCS,Outpatient,,,104.85,62.91,,19.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.4,70,,,percent of total billed charges,70% of total billed charges,78.64,75,,,percent of total billed charges,75% of total billed charges,9.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.25,350,,,Fee Schedule,350% of CMS OPPS Rate,5.61,102,,,Fee Schedule,102% of CMS OPPS Rate,80.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,47.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,6.11,100,,,Fee Schedule,100% of UHC Fee Schedule,73.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,12.65,230,,,Fee Schedule,230% of CMS OPPS Rate,50.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,94.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,94.37,
VITAMIN A(RETINOL),4080035,CDM,301,RC,84590,HCPCS,Outpatient,,,222.75,133.65,,41.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.93,70,,,percent of total billed charges,70% of total billed charges,167.06,75,,,percent of total billed charges,75% of total billed charges,20.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.63,350,,,Fee Schedule,350% of CMS OPPS Rate,11.84,102,,,Fee Schedule,102% of CMS OPPS Rate,170.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of UHC Fee Schedule,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.7,230,,,Fee Schedule,230% of CMS OPPS Rate,106.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,200.48,
EPINEPHRINE PLASMA,4080037,CDM,301,RC,82383,HCPCS,Outpatient,,,94.5,56.7,,102.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,52.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.78,350,,,Fee Schedule,350% of CMS OPPS Rate,29.66,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,66.88,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,29.08,100,,,Fee Schedule,100% of CMS OPPS Rate,27.84,102.94,
FACTOR V ACTIVITY,4080047,CDM,305,RC,85220,HCPCS,Outpatient,,,110,66,,62.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77,70,,,percent of total billed charges,70% of total billed charges,82.5,75,,,percent of total billed charges,75% of total billed charges,31.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.77,350,,,Fee Schedule,350% of CMS OPPS Rate,18,102,,,Fee Schedule,102% of CMS OPPS Rate,84.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of UHC Fee Schedule,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,230,,,Fee Schedule,230% of CMS OPPS Rate,52.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,99,
FOLATE RBC,4080056,CDM,301,RC,82747,HCPCS,Outpatient,,,90.5,54.3,,62.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,31.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.77,350,,,Fee Schedule,350% of CMS OPPS Rate,18,102,,,Fee Schedule,102% of CMS OPPS Rate,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,19.24,100,,,Fee Schedule,100% of UHC Fee Schedule,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,230,,,Fee Schedule,230% of CMS OPPS Rate,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,100,,,Fee Schedule,100% of CMS OPPS Rate,17.64,81.45,
VISCOSITY PLASMA,4080059,CDM,305,RC,85810,HCPCS,Outpatient,,,41.8,25.08,,41.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.26,70,,,percent of total billed charges,70% of total billed charges,31.35,75,,,percent of total billed charges,75% of total billed charges,21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,33.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.84,350,,,Fee Schedule,350% of CMS OPPS Rate,11.9,102,,,Fee Schedule,102% of CMS OPPS Rate,31.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,12.97,100,,,Fee Schedule,100% of UHC Fee Schedule,29.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,26.84,230,,,Fee Schedule,230% of CMS OPPS Rate,20.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,37.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.67,41.31,
KETONE BODY ACETONE QUANT,4080067,CDM,300,RC,82010,HCPCS,Outpatient,,,46.8,28.08,,28.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.76,70,,,percent of total billed charges,70% of total billed charges,35.1,75,,,percent of total billed charges,75% of total billed charges,14.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.59,350,,,Fee Schedule,350% of CMS OPPS Rate,8.33,102,,,Fee Schedule,102% of CMS OPPS Rate,35.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,9.08,100,,,Fee Schedule,100% of UHC Fee Schedule,32.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,230,,,Fee Schedule,230% of CMS OPPS Rate,22.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,42.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,100,,,Fee Schedule,100% of CMS OPPS Rate,8.17,42.12,
IGE SPECIFIC ALLERGINS,4080069,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
OSMOTIC FRAG.RBC INCUBATE,4080071,CDM,305,RC,85557,HCPCS,Outpatient,,,56.5,33.9,,47.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.55,70,,,percent of total billed charges,70% of total billed charges,42.38,75,,,percent of total billed charges,75% of total billed charges,24.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,45.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.76,350,,,Fee Schedule,350% of CMS OPPS Rate,13.62,102,,,Fee Schedule,102% of CMS OPPS Rate,43.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,25.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,100,,,Fee Schedule,100% of UHC Fee Schedule,39.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,30.72,230,,,Fee Schedule,230% of CMS OPPS Rate,27.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,50.85,
"ANTIBODY INFLU,RICKETTSIA",4080074,CDM,302,RC,86757,HCPCS,Outpatient,,,58,34.8,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,68.49,
"AGGLUTININS,FEBRILE",4080075,CDM,302,RC,86000,HCPCS,Outpatient,,,24,14.4,,24.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,16.8,70,,,percent of total billed charges,70% of total billed charges,18,75,,,percent of total billed charges,75% of total billed charges,12.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,19.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.43,350,,,Fee Schedule,350% of CMS OPPS Rate,7.11,102,,,Fee Schedule,102% of CMS OPPS Rate,18.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7.76,100,,,Fee Schedule,100% of UHC Fee Schedule,16.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,230,,,Fee Schedule,230% of CMS OPPS Rate,11.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,21.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,24.7,
VITAMIN E,4080076,CDM,301,RC,84446,HCPCS,Outpatient,,,89.1,53.46,,50.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,25.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.63,350,,,Fee Schedule,350% of CMS OPPS Rate,14.46,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,80.19,
ISOPROPANOL,4080082,CDM,301,RC,84600,HCPCS,Outpatient,,,46,27.6,,60.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,30.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.88,350,,,Fee Schedule,350% of CMS OPPS Rate,17.45,102,,,Fee Schedule,102% of CMS OPPS Rate,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.87,100,,,Fee Schedule,100% of UHC Fee Schedule,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,39.35,230,,,Fee Schedule,230% of CMS OPPS Rate,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,100,,,Fee Schedule,100% of CMS OPPS Rate,17.11,60.56,
HOMOCYSTEINE ULTRAQUANT,4080085,CDM,301,RC,83090,HCPCS,Outpatient,,,123.75,74.25,,63.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges,92.81,75,,,percent of total billed charges,75% of total billed charges,32.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.72,350,,,Fee Schedule,350% of CMS OPPS Rate,18.27,102,,,Fee Schedule,102% of CMS OPPS Rate,94.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of UHC Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,41.21,230,,,Fee Schedule,230% of CMS OPPS Rate,59.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.92,111.38,
VON WILLEBRAND MULTIMERS,4080088,CDM,305,RC,85247,HCPCS,Outpatient,,,91.3,54.78,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges,68.48,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,69.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,43.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,82.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,82.17,
RISTOCETIN COFACTOR,4080089,CDM,305,RC,85245,HCPCS,Outpatient,,,91.3,54.78,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges,68.48,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,69.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,43.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,82.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,82.17,
BORRELIA B. ABS CONFIRM,4080090,CDM,302,RC,86617,HCPCS,Outpatient,,,54.45,32.67,,54.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.21,350,,,Fee Schedule,350% of CMS OPPS Rate,15.79,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,35.62,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,54.83,
BORRELIA B. ABS,4080091,CDM,302,RC,86618,HCPCS,Outpatient,,,152.35,91.41,,60.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,30.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.6,350,,,Fee Schedule,350% of CMS OPPS Rate,17.37,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,18.92,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,39.16,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,137.12,
HEPATITIS C CONFIRM,4080095,CDM,302,RC,86804,HCPCS,Outpatient,,,182.25,109.35,,54.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.58,70,,,percent of total billed charges,70% of total billed charges,136.69,75,,,percent of total billed charges,75% of total billed charges,27.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.21,350,,,Fee Schedule,350% of CMS OPPS Rate,15.79,102,,,Fee Schedule,102% of CMS OPPS Rate,139.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,82.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of UHC Fee Schedule,127.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,35.62,230,,,Fee Schedule,230% of CMS OPPS Rate,87.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,164.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,164.03,
AMINO ACID QUANT.,4080100,CDM,301,RC,82139,HCPCS,Outpatient,,,656.5,393.9,,59.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,459.55,70,,,percent of total billed charges,70% of total billed charges,492.38,75,,,percent of total billed charges,75% of total billed charges,30.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,525.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.04,350,,,Fee Schedule,350% of CMS OPPS Rate,17.2,102,,,Fee Schedule,102% of CMS OPPS Rate,502.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,295.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,459.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,393.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of UHC Fee Schedule,459.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,38.8,230,,,Fee Schedule,230% of CMS OPPS Rate,315.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,590.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,590.85,
ENTAMOEBA HISTOLYTICA ABS,4080102,CDM,302,RC,86753,HCPCS,Outpatient,,,138.5,83.1,,43.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.95,70,,,percent of total billed charges,70% of total billed charges,103.88,75,,,percent of total billed charges,75% of total billed charges,22.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.36,350,,,Fee Schedule,350% of CMS OPPS Rate,12.63,102,,,Fee Schedule,102% of CMS OPPS Rate,105.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,62.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of UHC Fee Schedule,96.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,28.49,230,,,Fee Schedule,230% of CMS OPPS Rate,66.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,124.65,
ESTRIOL(ALPHA FETOPROTEIN,4080103,CDM,301,RC,82677,HCPCS,Outpatient,,,73,43.8,,85.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.1,70,,,percent of total billed charges,70% of total billed charges,54.75,75,,,percent of total billed charges,75% of total billed charges,43.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.63,350,,,Fee Schedule,350% of CMS OPPS Rate,24.66,102,,,Fee Schedule,102% of CMS OPPS Rate,55.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,32.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,26.87,100,,,Fee Schedule,100% of UHC Fee Schedule,51.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,55.61,230,,,Fee Schedule,230% of CMS OPPS Rate,35.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,65.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,85.59,
5 HIAA 24HR URINE,4080110,CDM,301,RC,83497,HCPCS,Outpatient,,,146.7,88.02,,45.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.69,70,,,percent of total billed charges,70% of total billed charges,110.03,75,,,percent of total billed charges,75% of total billed charges,23.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,117.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.15,350,,,Fee Schedule,350% of CMS OPPS Rate,13.15,102,,,Fee Schedule,102% of CMS OPPS Rate,112.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,66.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of UHC Fee Schedule,102.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,29.67,230,,,Fee Schedule,230% of CMS OPPS Rate,70.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,132.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,132.03,
PLATELET ASSOCIATED ABS,4080111,CDM,302,RC,86023,HCPCS,Outpatient,,,74.12,44.47,,44.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.88,70,,,percent of total billed charges,70% of total billed charges,55.59,75,,,percent of total billed charges,75% of total billed charges,22.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.61,350,,,Fee Schedule,350% of CMS OPPS Rate,12.7,102,,,Fee Schedule,102% of CMS OPPS Rate,56.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of UHC Fee Schedule,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,28.65,230,,,Fee Schedule,230% of CMS OPPS Rate,35.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,66.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,66.71,
BRUCELLA ABORTUS ABS,4080112,CDM,302,RC,86622,HCPCS,Outpatient,,,36,21.6,,31.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges,27,75,,,percent of total billed charges,75% of total billed charges,16.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.25,350,,,Fee Schedule,350% of CMS OPPS Rate,9.1,102,,,Fee Schedule,102% of CMS OPPS Rate,27.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of UHC Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,20.53,230,,,Fee Schedule,230% of CMS OPPS Rate,17.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,32.4,
CARNITINE TOTAL,4080113,CDM,301,RC,82379,HCPCS,Outpatient,,,289,173.4,,59.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,202.3,70,,,percent of total billed charges,70% of total billed charges,216.75,75,,,percent of total billed charges,75% of total billed charges,30.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,231.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.04,350,,,Fee Schedule,350% of CMS OPPS Rate,17.2,102,,,Fee Schedule,102% of CMS OPPS Rate,221.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,202.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of UHC Fee Schedule,202.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,38.8,230,,,Fee Schedule,230% of CMS OPPS Rate,138.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,260.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,260.1,
"SPECTROPHOTOMETRY ANALYTE, OTHER",4080124,CDM,301,RC,84311,HCPCS,Outpatient,,,113.4,68.04,,28.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.1,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges,85.05,75,,,percent of total billed charges,75% of total billed charges,14.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.35,350,,,Fee Schedule,350% of CMS OPPS Rate,8.26,102,,,Fee Schedule,102% of CMS OPPS Rate,86.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of UHC Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,18.63,230,,,Fee Schedule,230% of CMS OPPS Rate,54.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.1,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,102.06,
IGG SUBCLASS,4080125,CDM,301,RC,82787,HCPCS,Outpatient,,,93.5,56.1,,28.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.45,70,,,percent of total billed charges,70% of total billed charges,70.13,75,,,percent of total billed charges,75% of total billed charges,14.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.07,350,,,Fee Schedule,350% of CMS OPPS Rate,8.18,102,,,Fee Schedule,102% of CMS OPPS Rate,71.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,42.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.91,100,,,Fee Schedule,100% of UHC Fee Schedule,65.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,230,,,Fee Schedule,230% of CMS OPPS Rate,44.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,84.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6.75,84.15,
TETANUS TOXOID IGG ABS,4080127,CDM,302,RC,86774,HCPCS,Outpatient,,,54.9,32.94,,52.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,26.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.8,350,,,Fee Schedule,350% of CMS OPPS Rate,15.09,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.44,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,52.39,
DIPTHERIA TOXOID IGG ABS,4080128,CDM,302,RC,86648,HCPCS,Outpatient,,,54.9,32.94,,53.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,27.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.23,350,,,Fee Schedule,350% of CMS OPPS Rate,15.51,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,34.98,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,53.84,
LYPHOCYTES/GATED CELLS,4080130,CDM,302,RC,86359,HCPCS,Outpatient,,,127,76.2,,133.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,67.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.05,350,,,Fee Schedule,350% of CMS OPPS Rate,38.48,102,,,Fee Schedule,102% of CMS OPPS Rate,97.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of UHC Fee Schedule,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,230,,,Fee Schedule,230% of CMS OPPS Rate,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,114.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,133.56,
CHLAMYDIA TRACHOMATIS,4080131,CDM,306,RC,87270,HCPCS,Outpatient,,,53.5,32.1,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,48.15,
BORDETELLA PERTUSSIS DFA,4080138,CDM,306,RC,87265,HCPCS,Outpatient,,,61,36.6,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,54.9,
ASPERGILLUS ABS,4080150,CDM,302,RC,86606,HCPCS,Outpatient,,,50.6,30.36,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
EXTRACTABLE N AG IGG ABS,4080154,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
DRUG ASSAY CYCLOSPORINE,4080158,CDM,301,RC,80158,HCPCS,Outpatient,,,129.6,77.76,,63.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.72,70,,,percent of total billed charges,70% of total billed charges,97.2,75,,,percent of total billed charges,75% of total billed charges,32.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.17,350,,,Fee Schedule,350% of CMS OPPS Rate,18.41,102,,,Fee Schedule,102% of CMS OPPS Rate,99.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,58.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of UHC Fee Schedule,90.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,41.51,230,,,Fee Schedule,230% of CMS OPPS Rate,62.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,116.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,116.64,
DRUG ASSAY CLOZAPINE,4080159,CDM,300,RC,80159,HCPCS,Outpatient,,,176,105.6,,71.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges,132,75,,,percent of total billed charges,75% of total billed charges,36.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.52,350,,,Fee Schedule,350% of CMS OPPS Rate,20.55,102,,,Fee Schedule,102% of CMS OPPS Rate,134.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.55,100,,,Fee Schedule,100% of UHC Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,46.34,230,,,Fee Schedule,230% of CMS OPPS Rate,84.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,158.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.14,158.4,
CHROM ANALY 15 - 20 CELLS,4080162,CDM,311,RC,88262,HCPCS,Outpatient,,,423.45,254.07,,444.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,125.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,313.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,296.42,70,,,percent of total billed charges,70% of total billed charges,317.59,75,,,percent of total billed charges,75% of total billed charges,225.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,338.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,439.21,350,,,Fee Schedule,350% of CMS OPPS Rate,127.99,102,,,Fee Schedule,102% of CMS OPPS Rate,323.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of UHC Fee Schedule,296.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,288.62,230,,,Fee Schedule,230% of CMS OPPS Rate,203.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,381.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,444.23,
Blood test to determine existence of certain bacterium that causes syphilis,4080165,CDM,302,RC,86780,HCPCS,Outpatient,,,82.35,49.41,,46.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.65,70,,,percent of total billed charges,70% of total billed charges,61.76,75,,,percent of total billed charges,75% of total billed charges,23.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.34,350,,,Fee Schedule,350% of CMS OPPS Rate,13.5,102,,,Fee Schedule,102% of CMS OPPS Rate,63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,37.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of UHC Fee Schedule,57.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,30.45,230,,,Fee Schedule,230% of CMS OPPS Rate,39.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,74.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,74.12,
FRUCTOSAMINE,4080168,CDM,301,RC,82985,HCPCS,Outpatient,,,49.5,29.7,,59.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,30.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.66,350,,,Fee Schedule,350% of CMS OPPS Rate,17.09,102,,,Fee Schedule,102% of CMS OPPS Rate,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of UHC Fee Schedule,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.54,230,,,Fee Schedule,230% of CMS OPPS Rate,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,59.33,
APERGILLUS PREC. ID,4080169,CDM,302,RC,86329,HCPCS,Outpatient,,,94.5,56.7,,49.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,25.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.17,350,,,Fee Schedule,350% of CMS OPPS Rate,14.33,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.61,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,32.31,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.05,85.05,
GIARDIA AG DETECTION EIA,4080175,CDM,306,RC,87329,HCPCS,Outpatient,,,78.65,47.19,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges,58.99,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,60.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,35.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,37.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,70.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,70.79,
MASS SPECTROMETRY QUAL/QUANT,4080177,CDM,301,RC,83789,HCPCS,Outpatient,,,122,73.2,,85.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.4,70,,,percent of total billed charges,70% of total billed charges,91.5,75,,,percent of total billed charges,75% of total billed charges,43.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.38,350,,,Fee Schedule,350% of CMS OPPS Rate,24.59,102,,,Fee Schedule,102% of CMS OPPS Rate,93.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of UHC Fee Schedule,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,55.45,230,,,Fee Schedule,230% of CMS OPPS Rate,58.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,109.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,109.8,
CHLAMYDIA PNEUM. ABS,4080178,CDM,302,RC,86631,HCPCS,Outpatient,,,71.1,42.66,,41.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.82,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49.77,70,,,percent of total billed charges,70% of total billed charges,53.33,75,,,percent of total billed charges,75% of total billed charges,21.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.37,350,,,Fee Schedule,350% of CMS OPPS Rate,12.05,102,,,Fee Schedule,102% of CMS OPPS Rate,54.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.14,100,,,Fee Schedule,100% of UHC Fee Schedule,49.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,27.18,230,,,Fee Schedule,230% of CMS OPPS Rate,34.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,63.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,63.99,
PSA (prostate specific antigen) measurement,4080184,CDM,301,RC,84154,HCPCS,Outpatient,,,55,33,,65.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.5,70,,,percent of total billed charges,70% of total billed charges,41.25,75,,,percent of total billed charges,75% of total billed charges,33.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.36,350,,,Fee Schedule,350% of CMS OPPS Rate,18.75,102,,,Fee Schedule,102% of CMS OPPS Rate,42.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.29,230,,,Fee Schedule,230% of CMS OPPS Rate,26.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,65.1,
ELECTRON MICROSCOPY,4080186,CDM,312,RC,88348,HCPCS,Outpatient,,,1205,723,,2498.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1102.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,843.5,70,,,percent of total billed charges,70% of total billed charges,903.75,75,,,percent of total billed charges,75% of total billed charges,1270.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,964,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.73,350,,,Fee Schedule,350% of CMS OPPS Rate,720.04,103,,,Fee Schedule,103% of CMS OPPS Rate,921.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,542.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,843.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,723,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,486.86,100,,,Fee Schedule,100% of UHC Fee Schedule,843.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.62,100,,,Fee Schedule,100% of CMS OPPS Rate,578.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,111.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,111.73,2498.97,
IMMUNOFLUOR ANTB 1ST STAIN,4080187,CDM,312,RC,88346,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,1043.05,
FACTOR II ACTIVITY,4080188,CDM,305,RC,85210,HCPCS,Outpatient,,,100,60,,45.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,23.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.43,350,,,Fee Schedule,350% of CMS OPPS Rate,13.23,102,,,Fee Schedule,102% of CMS OPPS Rate,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.43,100,,,Fee Schedule,100% of UHC Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,230,,,Fee Schedule,230% of CMS OPPS Rate,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,12.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7.04,90,
METHADONE,4080197,CDM,301,RC,80358,HCPCS,Outpatient,,,188,112.8,,,,,,Other,Not Separately reimbursable,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.6,70,,,percent of total billed charges,70% of total billed charges,141,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,150.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,169.2,
"CULTURE, AFB",4080201,CDM,306,RC,87116,HCPCS,Outpatient,,,57.6,34.56,,38.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges,43.2,75,,,percent of total billed charges,75% of total billed charges,19.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,350,,,Fee Schedule,350% of CMS OPPS Rate,11.01,102,,,Fee Schedule,102% of CMS OPPS Rate,44.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,25.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of UHC Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,24.84,230,,,Fee Schedule,230% of CMS OPPS Rate,27.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,51.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,51.84,
HISTOCHEM.STAIN(TULANE MC,4080220,CDM,312,RC,88314,HCPCS,Outpatient,,,162,97.2,,,,,,Other,Not Separately reimbursable,38.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.02,100,,,Fee Schedule,100% of UHC Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.17,145.8,
HERPES SIM.VIRUS 1 ABS,4080222,CDM,302,RC,86695,HCPCS,Outpatient,,,45.1,27.06,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
AG DETECT NOS IA MULT,4080236,CDM,306,RC,87449,HCPCS,Outpatient,,,60.3,36.18,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42.21,70,,,percent of total billed charges,70% of total billed charges,45.23,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,46.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,42.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,28.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,54.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,54.27,
"NICKEL, URINE",4080238,CDM,301,RC,83885,HCPCS,Outpatient,,,81.95,49.17,,86.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges,61.46,75,,,percent of total billed charges,75% of total billed charges,44.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.78,350,,,Fee Schedule,350% of CMS OPPS Rate,25,102,,,Fee Schedule,102% of CMS OPPS Rate,62.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,36.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,27.23,100,,,Fee Schedule,100% of UHC Fee Schedule,57.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.37,230,,,Fee Schedule,230% of CMS OPPS Rate,39.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,100,,,Fee Schedule,100% of CMS OPPS Rate,24.51,86.76,
CYROFIBRINOGEN,4080239,CDM,301,RC,82585,HCPCS,Outpatient,,,90.5,54.3,,50.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,25.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.49,350,,,Fee Schedule,350% of CMS OPPS Rate,14.42,102,,,Fee Schedule,102% of CMS OPPS Rate,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,12.73,100,,,Fee Schedule,100% of UHC Fee Schedule,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32.52,230,,,Fee Schedule,230% of CMS OPPS Rate,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,11.04,81.45,
CHLAMYDIA PNEUM. IGM ABS,4080240,CDM,302,RC,86632,HCPCS,Outpatient,,,67.05,40.23,,44.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.94,70,,,percent of total billed charges,70% of total billed charges,50.29,75,,,percent of total billed charges,75% of total billed charges,22.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.38,350,,,Fee Schedule,350% of CMS OPPS Rate,12.93,102,,,Fee Schedule,102% of CMS OPPS Rate,51.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,14.09,100,,,Fee Schedule,100% of UHC Fee Schedule,46.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.16,230,,,Fee Schedule,230% of CMS OPPS Rate,32.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.68,60.35,
"COMPLEMENT AG,FUCTIONAL",4080245,CDM,302,RC,86161,HCPCS,Outpatient,,,80,48,,42.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,21.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,350,,,Fee Schedule,350% of CMS OPPS Rate,12.24,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,100% of UHC Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,27.6,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,72,
Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,4080247,CDM,301,RC,80197,HCPCS,Outpatient,,,103.05,61.83,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.14,70,,,percent of total billed charges,70% of total billed charges,77.29,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.05,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,78.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,46.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,15.26,100,,,Fee Schedule,100% of UHC Fee Schedule,72.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.57,230,,,Fee Schedule,230% of CMS OPPS Rate,49.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,92.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,92.75,
"VITAMIN, NOS",4080248,CDM,301,RC,84591,HCPCS,Outpatient,,,84.15,50.49,,60.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.13,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.91,70,,,percent of total billed charges,70% of total billed charges,63.11,75,,,percent of total billed charges,75% of total billed charges,30.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,67.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.71,350,,,Fee Schedule,350% of CMS OPPS Rate,17.4,102,,,Fee Schedule,102% of CMS OPPS Rate,64.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,37.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.35,100,,,Fee Schedule,100% of UHC Fee Schedule,58.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,39.23,230,,,Fee Schedule,230% of CMS OPPS Rate,40.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,75.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.35,75.74,
ISLET CELL ABS,4080249,CDM,302,RC,86341,HCPCS,Outpatient,,,71,42.6,,83.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49.7,70,,,percent of total billed charges,70% of total billed charges,53.25,75,,,percent of total billed charges,75% of total billed charges,42.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.49,350,,,Fee Schedule,350% of CMS OPPS Rate,24.04,102,,,Fee Schedule,102% of CMS OPPS Rate,54.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of UHC Fee Schedule,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,54.21,230,,,Fee Schedule,230% of CMS OPPS Rate,34.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,63.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,83.43,
MYCOBACTERIUM TUB. PROBE,4080250,CDM,306,RC,87556,HCPCS,Outpatient,,,480.15,288.09,,147.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,336.11,70,,,percent of total billed charges,70% of total billed charges,360.11,75,,,percent of total billed charges,75% of total billed charges,75.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,384.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.88,350,,,Fee Schedule,350% of CMS OPPS Rate,42.51,102,,,Fee Schedule,102% of CMS OPPS Rate,367.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,216.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,336.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,95.86,230,,,Fee Schedule,230% of CMS OPPS Rate,230.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,432.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of CMS OPPS Rate,39,432.14,
PATHOLOGY CONSULT,4080251,CDM,312,RC,88321,HCPCS,Outpatient,,,232,139.2,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,56.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,162.4,70,,,percent of total billed charges,70% of total billed charges,174,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,177.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,104.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,111.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,208.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,208.8,
ETHYLENE GLYCOL,4080253,CDM,301,RC,82693,HCPCS,Outpatient,,,94.5,56.7,,52.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,26.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.15,350,,,Fee Schedule,350% of CMS OPPS Rate,15.19,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,34.27,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.9,85.05,
"LYSOZYME, SERUM",4080256,CDM,305,RC,85549,HCPCS,Outpatient,,,200.5,120.3,,66.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140.35,70,,,percent of total billed charges,70% of total billed charges,150.38,75,,,percent of total billed charges,75% of total billed charges,33.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.62,350,,,Fee Schedule,350% of CMS OPPS Rate,19.12,102,,,Fee Schedule,102% of CMS OPPS Rate,153.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,90.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,20.84,100,,,Fee Schedule,100% of UHC Fee Schedule,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,43.12,230,,,Fee Schedule,230% of CMS OPPS Rate,96.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,180.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,180.45,
MOLECULAR CYTOGENETICS,4080264,CDM,311,RC,88271,HCPCS,Outpatient,,,74.7,44.82,,75.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges,56.03,75,,,percent of total billed charges,75% of total billed charges,38.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.97,350,,,Fee Schedule,350% of CMS OPPS Rate,21.84,102,,,Fee Schedule,102% of CMS OPPS Rate,57.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,33.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,23.8,100,,,Fee Schedule,100% of UHC Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,230,,,Fee Schedule,230% of CMS OPPS Rate,35.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,75.82,
OLANZAPINE,4080278,CDM,300,RC,80342,HCPCS,Outpatient,,,163,97.8,,,,,,Other,Not Separately reimbursable,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.1,70,,,percent of total billed charges,70% of total billed charges,122.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,130.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.54,146.7,
SACCHAROMYCES CEREVIS.ABS,4080287,CDM,300,RC,86671,HCPCS,Outpatient,,,128.15,76.89,,43.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges,96.11,75,,,percent of total billed charges,75% of total billed charges,22.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,350,,,Fee Schedule,350% of CMS OPPS Rate,12.49,102,,,Fee Schedule,102% of CMS OPPS Rate,98.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,57.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of UHC Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,230,,,Fee Schedule,230% of CMS OPPS Rate,61.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,115.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,115.34,
IMMUNOASSAY RAD TECHNIQUE,4080289,CDM,300,RC,83519,HCPCS,Outpatient,,,149.05,89.43,,65.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,33.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.39,350,,,Fee Schedule,350% of CMS OPPS Rate,18.76,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,100,,,Fee Schedule,100% of UHC Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.32,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,134.15,
Blood test to monitor breast cancer,4080290,CDM,302,RC,86300,HCPCS,Outpatient,,,79.75,47.85,,73.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.83,70,,,percent of total billed charges,70% of total billed charges,59.81,75,,,percent of total billed charges,75% of total billed charges,37.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,63.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,350,,,Fee Schedule,350% of CMS OPPS Rate,21.22,102,,,Fee Schedule,102% of CMS OPPS Rate,61.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of UHC Fee Schedule,55.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.86,230,,,Fee Schedule,230% of CMS OPPS Rate,38.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,71.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,73.66,
BILE ACID; TOTAL,4080291,CDM,301,RC,82239,HCPCS,Outpatient,,,80,48,,60.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,30.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.92,350,,,Fee Schedule,350% of CMS OPPS Rate,17.46,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,19.03,100,,,Fee Schedule,100% of UHC Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.37,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,100,,,Fee Schedule,100% of CMS OPPS Rate,17.12,72,
"TOPIRAMATE, SERUM",4080295,CDM,300,RC,80201,HCPCS,Outpatient,,,140.5,84.3,,42.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.35,70,,,percent of total billed charges,70% of total billed charges,105.38,75,,,percent of total billed charges,75% of total billed charges,21.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.72,350,,,Fee Schedule,350% of CMS OPPS Rate,12.15,102,,,Fee Schedule,102% of CMS OPPS Rate,107.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,63.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of UHC Fee Schedule,98.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.41,230,,,Fee Schedule,230% of CMS OPPS Rate,67.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,126.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,100,,,Fee Schedule,100% of CMS OPPS Rate,11.92,126.45,
PROTEIN ELECTROPHORESIS,4080302,CDM,300,RC,84165,HCPCS,Outpatient,,,173.7,104.22,,38.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges,130.28,75,,,percent of total billed charges,75% of total billed charges,19.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.59,350,,,Fee Schedule,350% of CMS OPPS Rate,10.95,102,,,Fee Schedule,102% of CMS OPPS Rate,132.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of UHC Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.7,230,,,Fee Schedule,230% of CMS OPPS Rate,83.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,156.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,156.33,
PROTEIN ELECT.URINE RAND,4080304,CDM,300,RC,84166,HCPCS,Outpatient,,,261,156.6,,63.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges,195.75,75,,,percent of total billed charges,75% of total billed charges,32.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,350,,,Fee Schedule,350% of CMS OPPS Rate,18.18,102,,,Fee Schedule,102% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,100,,,Fee Schedule,100% of UHC Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,41,230,,,Fee Schedule,230% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,234.9,
"BENCE J. PROTEIN, 24HR UR",4080305,CDM,300,RC,82664,HCPCS,Outpatient,,,129.6,77.76,,217.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,61.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,125.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.72,70,,,percent of total billed charges,70% of total billed charges,97.2,75,,,percent of total billed charges,75% of total billed charges,110.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.25,350,,,Fee Schedule,350% of CMS OPPS Rate,62.73,102,,,Fee Schedule,102% of CMS OPPS Rate,99.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,58.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,55.35,100,,,Fee Schedule,100% of UHC Fee Schedule,90.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,230,,,Fee Schedule,230% of CMS OPPS Rate,62.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,116.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,61.5,100,,,Fee Schedule,100% of CMS OPPS Rate,13.56,217.71,
IMMUNOFIXATION ELECT.SER,4080308,CDM,302,RC,86334,HCPCS,Outpatient,,,85.05,51.03,,79.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,56.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.54,70,,,percent of total billed charges,70% of total billed charges,63.79,75,,,percent of total billed charges,75% of total billed charges,40.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.19,350,,,Fee Schedule,350% of CMS OPPS Rate,22.78,102,,,Fee Schedule,102% of CMS OPPS Rate,65.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.83,100,,,Fee Schedule,100% of UHC Fee Schedule,59.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,230,,,Fee Schedule,230% of CMS OPPS Rate,40.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,76.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,79.08,
"PHENYTOIN, FREE",4080318,CDM,300,RC,80186,HCPCS,Outpatient,,,54.9,32.94,,48.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges,41.18,75,,,percent of total billed charges,75% of total billed charges,24.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.16,350,,,Fee Schedule,350% of CMS OPPS Rate,14.03,102,,,Fee Schedule,102% of CMS OPPS Rate,42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of UHC Fee Schedule,38.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,230,,,Fee Schedule,230% of CMS OPPS Rate,26.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,49.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,49.41,
HPYLORI STOOL IA,4080319,CDM,300,RC,87338,HCPCS,Outpatient,,,127.05,76.23,,50.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.94,70,,,percent of total billed charges,70% of total billed charges,95.29,75,,,percent of total billed charges,75% of total billed charges,25.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.33,350,,,Fee Schedule,350% of CMS OPPS Rate,14.66,102,,,Fee Schedule,102% of CMS OPPS Rate,97.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,57.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,15.98,100,,,Fee Schedule,100% of UHC Fee Schedule,88.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,33.07,230,,,Fee Schedule,230% of CMS OPPS Rate,60.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,114.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,114.35,
ALCOHOL BIOMARKERS 1 OR 2,4080321,CDM,300,RC,80321,HCPCS,Outpatient,,,216,129.6,,,,,,Other,Not Separately reimbursable,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,194.4,
LEVETIRACETAM,4080332,CDM,301,RC,80177,HCPCS,Outpatient,,,204,122.4,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,142.8,70,,,percent of total billed charges,70% of total billed charges,153,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,156.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,91.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,142.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,97.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,183.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,183.6,
Blood test to monitor vitamin D levels,4080333,CDM,301,RC,82306,HCPCS,Outpatient,,,89,53.4,,104.78,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,53.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.6,350,,,Fee Schedule,350% of CMS OPPS Rate,30.19,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,32.9,100,,,Fee Schedule,100% of UHC Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,68.08,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,104.78,
"ANTIEPILEPTICS, OTHER",4080339,CDM,300,RC,80299,HCPCS,Outpatient,,,342,205.2,,65.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,239.4,70,,,percent of total billed charges,70% of total billed charges,256.5,75,,,percent of total billed charges,75% of total billed charges,33.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.24,350,,,Fee Schedule,350% of CMS OPPS Rate,19.01,102,,,Fee Schedule,102% of CMS OPPS Rate,261.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,153.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,239.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.78,100,,,Fee Schedule,100% of UHC Fee Schedule,239.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.87,230,,,Fee Schedule,230% of CMS OPPS Rate,164.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,307.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.78,307.8,
"OXCARBAZEPINE, SERUM",4080341,CDM,301,RC,80183,HCPCS,Outpatient,,,104,62.4,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,93.6,
VIRUS ISOLATE;ADDTL OR ID,4080342,CDM,306,RC,87253,HCPCS,Outpatient,,,135.5,81.3,,71.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,36.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.7,350,,,Fee Schedule,350% of CMS OPPS Rate,20.6,102,,,Fee Schedule,102% of CMS OPPS Rate,103.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,22.45,100,,,Fee Schedule,100% of UHC Fee Schedule,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,46.46,230,,,Fee Schedule,230% of CMS OPPS Rate,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.2,121.95,
CRYPTOSPOR AG BY EIA,4080347,CDM,306,RC,87328,HCPCS,Outpatient,,,54,32.4,,48.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.82,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,24.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.37,350,,,Fee Schedule,350% of CMS OPPS Rate,14.09,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,48.92,
BUPRENOPHINE,4080348,CDM,301,RC,80348,HCPCS,Outpatient,,,200,120,,,,,,Other,Not Separately reimbursable,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,180,
"CANNABINOIDS, NATURAL CONFIRM",4080349,CDM,301,RC,80349,HCPCS,Outpatient,,,126.26,75.76,,,,,,Other,Not Separately reimbursable,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.38,70,,,percent of total billed charges,70% of total billed charges,94.7,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,101.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.78,113.63,
INFIXIMAB,4080350,CDM,300,RC,80230,HCPCS,Outpatient,,,404,242.4,,136.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202,50,,,percent of total billed charges,pays at 50% of total billed charges,282.8,70,,,percent of total billed charges,70% of total billed charges,303,75,,,percent of total billed charges,75% of total billed charges,69.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.99,350,,,Fee Schedule,350% of CMS OPPS Rate,39.34,102,,,Fee Schedule,102% of CMS OPPS Rate,309.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,181.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.71,100,,,Fee Schedule,100% of UHC Fee Schedule,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,88.71,230,,,Fee Schedule,230% of CMS OPPS Rate,193.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,363.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,29.86,363.6,
CANNABINOIDS SYNTHETIC 7 OR MORE,4080352,CDM,301,RC,80352,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,50,,,percent of total billed charges,pays at 50% of total billed charges,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,144,
BENZODIAZAPINES CONFIRM 1,4080353,CDM,301,RC,80346,HCPCS,Outpatient,,,49.95,29.97,,,,,,Other,Not Separately reimbursable,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,44.96,
ASSAY OF SIROLIMUS,4080359,CDM,301,RC,80195,HCPCS,Outpatient,,,139.05,83.43,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.34,70,,,percent of total billed charges,70% of total billed charges,104.29,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.05,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,106.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,62.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,15.26,100,,,Fee Schedule,100% of UHC Fee Schedule,97.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.57,230,,,Fee Schedule,230% of CMS OPPS Rate,66.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,125.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,125.15,
METHYPHENIDATE,4080360,CDM,300,RC,80360,HCPCS,Outpatient,,,140,84,,,,,,Other,Not Separately reimbursable,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98,70,,,percent of total billed charges,70% of total billed charges,105,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,112,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.94,126,
OXYCODONE CONFIRM,4080365,CDM,301,RC,80365,HCPCS,Outpatient,,,134,80.4,,,,,,Other,Not Separately reimbursable,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges,100.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,120.6,
"LIPOPROTEIN BLD,HR FRACTI",4080367,CDM,301,RC,83701,HCPCS,Outpatient,,,75.35,45.21,,119.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,69.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.75,70,,,percent of total billed charges,70% of total billed charges,56.51,75,,,percent of total billed charges,75% of total billed charges,60.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.51,350,,,Fee Schedule,350% of CMS OPPS Rate,34.53,102,,,Fee Schedule,102% of CMS OPPS Rate,57.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,100,,,Fee Schedule,100% of UHC Fee Schedule,52.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,75.35,230,,,Fee Schedule,230% of CMS OPPS Rate,36.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,67.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,119.86,
Blood test to diagnose rheumatoid arthritis,4080370,CDM,302,RC,86200,HCPCS,Outpatient,,,115.5,69.3,,45.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,23.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.32,350,,,Fee Schedule,350% of CMS OPPS Rate,13.2,102,,,Fee Schedule,102% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,29.78,230,,,Fee Schedule,230% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,103.95,
"STIMULANTS, SYNTHETIC",4080371,CDM,301,RC,80371,HCPCS,Outpatient,,,256,153.6,,,,,,Other,Not Separately reimbursable,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.12,230.4,
FACTOR INHIBITOR TEST,4080375,CDM,305,RC,85335,HCPCS,Outpatient,,,50,30,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,45.55,
HEAVY METAL: QUAN,4080379,CDM,301,RC,83018,HCPCS,Outpatient,,,165,99,,77.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,39.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.86,350,,,Fee Schedule,350% of CMS OPPS Rate,22.39,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,24.41,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,50.5,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,21.96,100,,,Fee Schedule,100% of CMS OPPS Rate,10.36,148.5,
HEPARIN ASSAY,4080380,CDM,305,RC,85520,HCPCS,Outpatient,,,176,105.6,,46.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges,132,75,,,percent of total billed charges,75% of total billed charges,23.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.81,350,,,Fee Schedule,350% of CMS OPPS Rate,13.35,102,,,Fee Schedule,102% of CMS OPPS Rate,134.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,14.54,100,,,Fee Schedule,100% of UHC Fee Schedule,123.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,30.1,230,,,Fee Schedule,230% of CMS OPPS Rate,84.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,158.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,158.4,
OPIATES CONFIRM,4080382,CDM,301,RC,80361,HCPCS,Outpatient,,,105,63,,,,,,Other,Not Separately reimbursable,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,94.5,
ASPERGUILLUS AG EIA,4080383,CDM,306,RC,87305,HCPCS,Outpatient,,,232.2,139.32,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,162.54,70,,,percent of total billed charges,70% of total billed charges,174.15,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,185.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,177.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,104.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,162.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,111.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,208.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,208.98,
DRUG QUANT NES,4080389,CDM,302,RC,80299,HCPCS,Outpatient,,,104,62.4,,65.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,33.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.24,350,,,Fee Schedule,350% of CMS OPPS Rate,19.01,102,,,Fee Schedule,102% of CMS OPPS Rate,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.78,100,,,Fee Schedule,100% of UHC Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.87,230,,,Fee Schedule,230% of CMS OPPS Rate,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.78,93.6,
ESTROGENS FRACTIONATED,4080390,CDM,301,RC,82671,HCPCS,Outpatient,,,229,137.4,,114.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,32.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,58.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.04,350,,,Fee Schedule,350% of CMS OPPS Rate,32.94,102,,,Fee Schedule,102% of CMS OPPS Rate,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,35.89,100,,,Fee Schedule,100% of UHC Fee Schedule,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,74.28,230,,,Fee Schedule,230% of CMS OPPS Rate,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.29,206.1,
CULTURE TYPING IMMUNOFLOUR,4080391,CDM,309,RC,87140,HCPCS,Outpatient,,,124,74.4,,19.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,10.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.49,350,,,Fee Schedule,350% of CMS OPPS Rate,5.68,102,,,Fee Schedule,102% of CMS OPPS Rate,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of UHC Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.81,230,,,Fee Schedule,230% of CMS OPPS Rate,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,111.6,
CULTURE MYCOPLASMA,4080392,CDM,309,RC,87109,HCPCS,Outpatient,,,276,165.6,,54.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.2,70,,,percent of total billed charges,70% of total billed charges,207,75,,,percent of total billed charges,75% of total billed charges,27.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.86,350,,,Fee Schedule,350% of CMS OPPS Rate,15.69,102,,,Fee Schedule,102% of CMS OPPS Rate,211.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,124.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,17.1,100,,,Fee Schedule,100% of UHC Fee Schedule,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,35.39,230,,,Fee Schedule,230% of CMS OPPS Rate,132.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,248.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.39,248.4,
MORPHOMETRIC ANALYSIS TUMOR,4080393,CDM,312,RC,88361,HCPCS,Outpatient,,,378,226.8,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,105.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,264.6,70,,,percent of total billed charges,70% of total billed charges,283.5,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,302.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,289.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,170.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,264.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,226.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,264.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,181.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,340.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,105.39,1043.05,
MORPHOMETRIC ANALYSIS IN SITU,4080394,CDM,312,RC,88367,HCPCS,Outpatient,,,804.6,482.76,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,563.22,70,,,percent of total billed charges,70% of total billed charges,603.45,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,643.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,615.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,362.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,563.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,563.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,386.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,724.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,98.24,1043.05,
AMINO ACIDS SINGLE QUANT EA,4080395,CDM,301,RC,82131,HCPCS,Outpatient,,,300,180,,81.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,41.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.43,350,,,Fee Schedule,350% of CMS OPPS Rate,23.43,102,,,Fee Schedule,102% of CMS OPPS Rate,229.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.68,100,,,Fee Schedule,100% of UHC Fee Schedule,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.85,230,,,Fee Schedule,230% of CMS OPPS Rate,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,270,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.68,270,
MOLECULAR CYTOGENETICS INTERF,4080396,CDM,311,RC,88274,HCPCS,Outpatient,,,302.4,181.44,,150.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,87.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,211.68,70,,,percent of total billed charges,70% of total billed charges,226.8,75,,,percent of total billed charges,75% of total billed charges,76.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.33,350,,,Fee Schedule,350% of CMS OPPS Rate,43.22,102,,,Fee Schedule,102% of CMS OPPS Rate,231.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,136.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,100,,,Fee Schedule,100% of UHC Fee Schedule,211.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,97.47,230,,,Fee Schedule,230% of CMS OPPS Rate,145.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,272.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,272.16,
PROTEIN WESTERN BLOT,4080397,CDM,301,RC,84182,HCPCS,Outpatient,,,88,52.8,,103.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,59.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,52.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.23,350,,,Fee Schedule,350% of CMS OPPS Rate,29.79,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,26.29,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,67.18,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,103.4,
SPECIAL STAIN W INTERP GRP III,4080398,CDM,312,RC,88319,HCPCS,Outpatient,,,257.5,154.5,,2498.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,257.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1102.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.25,70,,,percent of total billed charges,70% of total billed charges,193.13,75,,,percent of total billed charges,75% of total billed charges,1270.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,206,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.73,350,,,Fee Schedule,350% of CMS OPPS Rate,257.5,103,,,Fee Schedule,103% of CMS OPPS Rate,196.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,115.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,486.86,100,,,Fee Schedule,100% of UHC Fee Schedule,180.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.62,100,,,Fee Schedule,100% of CMS OPPS Rate,123.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,257.5,100,,,Fee Schedule,100% of CMS OPPS Rate,231.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,40.35,2498.97,
INFECTIOUS AGENT AG VARICELLA,4080399,CDM,309,RC,87290,HCPCS,Outpatient,,,190,114,,47.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,24.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.97,350,,,Fee Schedule,350% of CMS OPPS Rate,13.68,102,,,Fee Schedule,102% of CMS OPPS Rate,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,230,,,Fee Schedule,230% of CMS OPPS Rate,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,171,
INFECTIOUS AGENT AG HERPES2,4080400,CDM,309,RC,87273,HCPCS,Outpatient,,,80,48,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,72,
PROCALCITONIN  PCT,4080401,CDM,301,RC,84145,HCPCS,Outpatient,,,184.1,110.46,,96.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,128.87,70,,,percent of total billed charges,70% of total billed charges,138.08,75,,,percent of total billed charges,75% of total billed charges,48.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.27,350,,,Fee Schedule,350% of CMS OPPS Rate,27.76,102,,,Fee Schedule,102% of CMS OPPS Rate,140.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,82.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,100% of UHC Fee Schedule,128.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,62.6,230,,,Fee Schedule,230% of CMS OPPS Rate,88.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,165.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,27.22,100,,,Fee Schedule,100% of CMS OPPS Rate,25.57,165.69,
VERY LONG CHAIN FATTY ACID,4080402,CDM,301,RC,82726,HCPCS,Outpatient,,,550,330,,69.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,385,70,,,percent of total billed charges,70% of total billed charges,412.5,75,,,percent of total billed charges,75% of total billed charges,35.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.12,350,,,Fee Schedule,350% of CMS OPPS Rate,20.14,102,,,Fee Schedule,102% of CMS OPPS Rate,420.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,20.06,100,,,Fee Schedule,100% of UHC Fee Schedule,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,45.42,230,,,Fee Schedule,230% of CMS OPPS Rate,264,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,495,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,100,,,Fee Schedule,100% of CMS OPPS Rate,19.75,495,
CARBAMAXEPINE FREE,4080403,CDM,301,RC,80157,HCPCS,Outpatient,,,119.64,71.78,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.75,70,,,percent of total billed charges,70% of total billed charges,89.73,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,91.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,53.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,83.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,57.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,107.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,107.68,
CATACHOLAMINES TOTAL URINE,4080404,CDM,301,RC,82382,HCPCS,Outpatient,,,155.16,93.1,,96.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.13,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,108.61,70,,,percent of total billed charges,70% of total billed charges,116.37,75,,,percent of total billed charges,75% of total billed charges,49.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.55,350,,,Fee Schedule,350% of CMS OPPS Rate,27.84,102,,,Fee Schedule,102% of CMS OPPS Rate,118.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,24.57,100,,,Fee Schedule,100% of UHC Fee Schedule,108.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,62.79,230,,,Fee Schedule,230% of CMS OPPS Rate,74.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,139.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.13,139.64,
MACROSCOPIC EXAM ARTHROPOD,4080405,CDM,309,RC,87168,HCPCS,Outpatient,,,306,183.6,,15.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,214.2,70,,,percent of total billed charges,70% of total billed charges,229.5,75,,,percent of total billed charges,75% of total billed charges,7.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,244.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4.35,102,,,Fee Schedule,102% of CMS OPPS Rate,234.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,137.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.74,100,,,Fee Schedule,100% of UHC Fee Schedule,214.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,230,,,Fee Schedule,230% of CMS OPPS Rate,146.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,275.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,275.4,
LYMPH TRANSFORMATION,4080406,CDM,302,RC,86353,HCPCS,Outpatient,,,338,202.8,,173.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,236.6,70,,,percent of total billed charges,70% of total billed charges,253.5,75,,,percent of total billed charges,75% of total billed charges,88.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.6,350,,,Fee Schedule,350% of CMS OPPS Rate,50.01,102,,,Fee Schedule,102% of CMS OPPS Rate,258.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,152.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,236.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,54.48,100,,,Fee Schedule,100% of UHC Fee Schedule,236.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,112.76,230,,,Fee Schedule,230% of CMS OPPS Rate,162.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,304.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of CMS OPPS Rate,49.03,304.2,
MYCOPHENODATE,4080407,CDM,300,RC,80180,HCPCS,Outpatient,,,244,146.4,,63.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,170.8,70,,,percent of total billed charges,70% of total billed charges,183,75,,,percent of total billed charges,75% of total billed charges,32.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,195.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.17,350,,,Fee Schedule,350% of CMS OPPS Rate,18.41,102,,,Fee Schedule,102% of CMS OPPS Rate,186.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,109.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,170.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of UHC Fee Schedule,170.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,41.51,230,,,Fee Schedule,230% of CMS OPPS Rate,117.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,219.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,219.6,
LAMOTRIGINE,4080408,CDM,300,RC,80175,HCPCS,Outpatient,,,104,62.4,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,93.6,
ANGIOTENSIN II,4080409,CDM,301,RC,82163,HCPCS,Outpatient,,,178,106.8,,72.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,124.6,70,,,percent of total billed charges,70% of total billed charges,133.5,75,,,percent of total billed charges,75% of total billed charges,36.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.82,350,,,Fee Schedule,350% of CMS OPPS Rate,20.93,102,,,Fee Schedule,102% of CMS OPPS Rate,136.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,22.81,100,,,Fee Schedule,100% of UHC Fee Schedule,124.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,47.19,230,,,Fee Schedule,230% of CMS OPPS Rate,85.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,160.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,160.2,
INFECTIOUS AGENT BY DNA INFLUENZA,4080410,CDM,300,RC,87502,HCPCS,Outpatient,,,596,357.6,,339.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,95.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,417.2,70,,,percent of total billed charges,70% of total billed charges,447,75,,,percent of total billed charges,75% of total billed charges,172.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.3,350,,,Fee Schedule,350% of CMS OPPS Rate,97.71,102,,,Fee Schedule,102% of CMS OPPS Rate,455.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,268.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,100,,,Fee Schedule,100% of UHC Fee Schedule,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,220.34,230,,,Fee Schedule,230% of CMS OPPS Rate,286.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,536.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,95.8,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,536.4,
DOXEPIN,4080411,CDM,300,RC,G0480,HCPCS,Outpatient,,,81,48.6,,405.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,88.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,205.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.5,350,,,Fee Schedule,350% of CMS OPPS Rate,116.71,102,,,Fee Schedule,102% of CMS OPPS Rate,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,102.99,100,,,Fee Schedule,100% of UHC Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,81,230,,,Fee Schedule,230% of CMS OPPS Rate,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.45,405.08,
ZONISAMIDE,4080412,CDM,300,RC,80203,HCPCS,Outpatient,,,198,118.8,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.6,70,,,percent of total billed charges,70% of total billed charges,148.5,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,151.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,138.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,95.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,178.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,178.2,
LIPOPROTEIN BLD QUANT NMBR,4080413,CDM,301,RC,83704,HCPCS,Outpatient,,,215.2,129.12,,121.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,79.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,150.64,70,,,percent of total billed charges,70% of total billed charges,161.4,75,,,percent of total billed charges,75% of total billed charges,61.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.66,350,,,Fee Schedule,350% of CMS OPPS Rate,34.87,102,,,Fee Schedule,102% of CMS OPPS Rate,164.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,96.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,150.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of UHC Fee Schedule,150.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,78.63,230,,,Fee Schedule,230% of CMS OPPS Rate,103.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,193.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,100,,,Fee Schedule,100% of CMS OPPS Rate,34.19,193.68,
"ANTIDEPRESSANTS, TCA",4080416,CDM,300,RC,80299,HCPCS,Outpatient,,,104,62.4,,65.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,33.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.24,350,,,Fee Schedule,350% of CMS OPPS Rate,19.01,102,,,Fee Schedule,102% of CMS OPPS Rate,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.78,100,,,Fee Schedule,100% of UHC Fee Schedule,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.87,230,,,Fee Schedule,230% of CMS OPPS Rate,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,16.78,93.6,
LIPOPROTEIN A,4080417,CDM,301,RC,83695,HCPCS,Outpatient,,,190,114,,50.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,25.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.12,350,,,Fee Schedule,350% of CMS OPPS Rate,14.6,102,,,Fee Schedule,102% of CMS OPPS Rate,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of UHC Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,32.93,230,,,Fee Schedule,230% of CMS OPPS Rate,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,100,,,Fee Schedule,100% of CMS OPPS Rate,14.32,171,
ANTIBODY ID LEUKOCYTE ABS,4080418,CDM,302,RC,86021,HCPCS,Outpatient,,,54.45,32.67,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
ANCA SCREEN EA AB,4080418,CDM,300,RC,86036,HCPCS,Outpatient,,,110,66,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55,50,,,percent of total billed charges,pays at 50% of total billed charges,77,70,,,percent of total billed charges,70% of total billed charges,82.5,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,84.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,52.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,99,
INFECTIOUS AGENT BY DNA GI PATHGN,4080419,CDM,306,RC,87507,HCPCS,Outpatient,,,1250,750,,1475.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,416.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,875,70,,,percent of total billed charges,70% of total billed charges,937.5,75,,,percent of total billed charges,75% of total billed charges,750.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1458.73,350,,,Fee Schedule,350% of CMS OPPS Rate,425.11,102,,,Fee Schedule,102% of CMS OPPS Rate,956.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,562.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,875,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,463.1,100,,,Fee Schedule,100% of UHC Fee Schedule,875,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,958.59,230,,,Fee Schedule,230% of CMS OPPS Rate,600,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1125,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,1475.4,
LUTEINIZING RELEASE FACTOR,4080420,CDM,300,RC,83727,HCPCS,Outpatient,,,450,270,,60.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,30.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.16,350,,,Fee Schedule,350% of CMS OPPS Rate,17.53,102,,,Fee Schedule,102% of CMS OPPS Rate,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,19.1,100,,,Fee Schedule,100% of UHC Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,39.53,230,,,Fee Schedule,230% of CMS OPPS Rate,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,405,
AMPHETAMINE CONFIRMATION 2 OR 3,4080421,CDM,300,RC,80325,HCPCS,Outpatient,,,399.7,239.82,,,,,,Other,Not Separately reimbursable,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,279.79,70,,,percent of total billed charges,70% of total billed charges,299.78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,319.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,279.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,359.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,359.73,
CYTOMEGALOVIRUS NA QUAN,4080422,CDM,306,RC,87497,HCPCS,Outpatient,,,138.6,83.16,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges,103.95,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,106.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,66.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,151.65,
Blood test for vaginitis,4080423,CDM,306,RC,87510,HCPCS,Outpatient,,,136.6,81.96,,70.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,95.62,70,,,percent of total billed charges,70% of total billed charges,102.45,75,,,percent of total billed charges,75% of total billed charges,36.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.17,350,,,Fee Schedule,350% of CMS OPPS Rate,20.45,102,,,Fee Schedule,102% of CMS OPPS Rate,104.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,61.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of UHC Fee Schedule,95.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.11,230,,,Fee Schedule,230% of CMS OPPS Rate,65.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,122.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,122.94,
PROPOXYPHENE CONFIRM,4080424,CDM,301,RC,80367,HCPCS,Outpatient,,,190,114,,,,,,Other,Not Separately reimbursable,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,171,
VIRUS ISOLATION SHELL TECHNIQUE,4080425,CDM,300,RC,87254,HCPCS,Outpatient,,,247.1,148.26,,69.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,172.97,70,,,percent of total billed charges,70% of total billed charges,185.33,75,,,percent of total billed charges,75% of total billed charges,35.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,197.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.46,350,,,Fee Schedule,350% of CMS OPPS Rate,19.95,102,,,Fee Schedule,102% of CMS OPPS Rate,189.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,111.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,21.74,100,,,Fee Schedule,100% of UHC Fee Schedule,172.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,44.98,230,,,Fee Schedule,230% of CMS OPPS Rate,118.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,222.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,222.39,
GARDNERELLA V AMPLFD PROBE TECH,4080426,CDM,306,RC,87511,HCPCS,Outpatient,,,240.7,144.42,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.49,70,,,percent of total billed charges,70% of total billed charges,180.53,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,184.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,108.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,168.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,115.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,216.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,216.63,
STEREOISOMER ANALY SINGLE CLASS,4080427,CDM,301,RC,80374,HCPCS,Outpatient,,,222.9,133.74,,,,,,Other,Not Separately reimbursable,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.45,50,,,percent of total billed charges,pays at 50% of total billed charges,156.03,70,,,percent of total billed charges,70% of total billed charges,167.18,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,178.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.93,200.61,
CULTURE-CHLAMYDIA-MISC SP,4080428,CDM,306,RC,87110,HCPCS,Outpatient,,,50,30,,69.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,35.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.6,350,,,Fee Schedule,350% of CMS OPPS Rate,19.99,102,,,Fee Schedule,102% of CMS OPPS Rate,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21.77,100,,,Fee Schedule,100% of UHC Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,45.08,230,,,Fee Schedule,230% of CMS OPPS Rate,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,69.38,
CULTURE TYPING IMMUNOFLOUR,4080428,CDM,309,RC,87140,HCPCS,Outpatient,,,124,74.4,,19.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,10.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.49,350,,,Fee Schedule,350% of CMS OPPS Rate,5.68,102,,,Fee Schedule,102% of CMS OPPS Rate,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of UHC Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.81,230,,,Fee Schedule,230% of CMS OPPS Rate,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,111.6,
"IMMUNOASSAY, INFECTIOUS A",4080429,CDM,302,RC,86317,HCPCS,Outpatient,,,93.6,56.16,,53.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.52,70,,,percent of total billed charges,70% of total billed charges,70.2,75,,,percent of total billed charges,75% of total billed charges,26.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.46,350,,,Fee Schedule,350% of CMS OPPS Rate,15.28,102,,,Fee Schedule,102% of CMS OPPS Rate,71.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,42.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,16.65,100,,,Fee Schedule,100% of UHC Fee Schedule,65.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,34.47,230,,,Fee Schedule,230% of CMS OPPS Rate,44.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,84.24,
LIPOPROTEIN,4080430,CDM,301,RC,82172,HCPCS,Outpatient,,,68.2,40.92,,74.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges,51.15,75,,,percent of total billed charges,75% of total billed charges,37.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.81,350,,,Fee Schedule,350% of CMS OPPS Rate,21.51,102,,,Fee Schedule,102% of CMS OPPS Rate,52.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,30.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,18.98,100,,,Fee Schedule,100% of UHC Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,48.5,230,,,Fee Schedule,230% of CMS OPPS Rate,32.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.69,74.65,
CULTURE TYPING ID BY NUCLEIC A. SEQUENCE,4080431,CDM,300,RC,87153,HCPCS,Outpatient,,,712.1,427.26,,408.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,115.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,290.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,498.47,70,,,percent of total billed charges,70% of total billed charges,534.08,75,,,percent of total billed charges,75% of total billed charges,207.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,569.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,403.76,350,,,Fee Schedule,350% of CMS OPPS Rate,117.66,102,,,Fee Schedule,102% of CMS OPPS Rate,544.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,320.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,498.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,128.18,100,,,Fee Schedule,100% of UHC Fee Schedule,498.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,265.32,230,,,Fee Schedule,230% of CMS OPPS Rate,341.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,640.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,115.36,640.89,
METHYLENEDIOXYAMPHETAMINE QUANT,4080432,CDM,300,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
OPIOIDS AND OPIATE ANALOGS 1 -2C,4080433,CDM,300,RC,80362,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,144,
IMMUNOASSAY ANALYTE,4080434,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
IMMUNOASSAY RAD TECHNIQUE,4080434,CDM,300,RC,83519,HCPCS,Outpatient,,,149.05,89.43,,65.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,33.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.39,350,,,Fee Schedule,350% of CMS OPPS Rate,18.76,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,100,,,Fee Schedule,100% of UHC Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.32,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,134.15,
FLORESCENT CHEM ABS,4080434,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
CULTURE TYPING GAS HIGH PRESSURE GLC,4080435,CDM,300,RC,87143,HCPCS,Outpatient,,,80.52,48.31,,44.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.36,70,,,percent of total billed charges,70% of total billed charges,60.39,75,,,percent of total billed charges,75% of total billed charges,22.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.82,350,,,Fee Schedule,350% of CMS OPPS Rate,12.77,102,,,Fee Schedule,102% of CMS OPPS Rate,61.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,36.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.91,100,,,Fee Schedule,100% of UHC Fee Schedule,56.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,28.79,230,,,Fee Schedule,230% of CMS OPPS Rate,38.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,72.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,72.47,
AMPLIFICATION GENE REARRANGE,4080436,CDM,310,RC,,,Outpatient,,,8750,5250,,,,,,Other,Not Separately reimbursable,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4375,50,,,percent of total billed charges,pays at 50% of total billed charges,6125,70,,,percent of total billed charges,70% of total billed charges,6562.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,7000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6693.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3937.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6125,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5250,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3325,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6125,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4200,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7875,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1371.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1371.13,7875,
ADALIMUMAB,4080437,CDM,300,RC,80145,HCPCS,Outpatient,,,626,375.6,,136.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,313,50,,,percent of total billed charges,pays at 50% of total billed charges,438.2,70,,,percent of total billed charges,70% of total billed charges,469.5,75,,,percent of total billed charges,75% of total billed charges,69.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.99,350,,,Fee Schedule,350% of CMS OPPS Rate,39.34,102,,,Fee Schedule,102% of CMS OPPS Rate,478.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,281.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,375.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.71,100,,,Fee Schedule,100% of UHC Fee Schedule,438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,88.71,230,,,Fee Schedule,230% of CMS OPPS Rate,300.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,563.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,29.86,563.4,
SAR COVID-19,4080439,CDM,300,RC,U0002,HCPCS,Outpatient,,,714,428.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,100,,,Fee Schedule,100% of UHC Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,642.6,
POSACONAZOLE,4080440,CDM,300,RC,80187,HCPCS,Outpatient,,,342,205.2,,95.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,171,50,,,percent of total billed charges,pays at 50% of total billed charges,239.4,70,,,percent of total billed charges,70% of total billed charges,256.5,75,,,percent of total billed charges,75% of total billed charges,48.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,273.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.88,350,,,Fee Schedule,350% of CMS OPPS Rate,27.65,102,,,Fee Schedule,102% of CMS OPPS Rate,261.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,153.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,239.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,205.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,100,,,Fee Schedule,100% of UHC Fee Schedule,239.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,62.35,230,,,Fee Schedule,230% of CMS OPPS Rate,164.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,307.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.98,307.8,
SAR COVID-19 HIGH THROUGHPUT,4080441,CDM,300,RC,U0003,HCPCS,Outpatient,,,714,428.4,,,,,,Other,Not Separately reimbursable,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357,50,,,percent of total billed charges,pays at 50% of total billed charges,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.88,642.6,
AMPHETAMINE CONFIRMATION 2 OR 3,4080442,CDM,300,RC,80325,HCPCS,Outpatient,,,399.7,239.82,,,,,,Other,Not Separately reimbursable,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,279.79,70,,,percent of total billed charges,70% of total billed charges,299.78,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,319.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,279.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,359.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,359.73,
METHYLENEDIOXYAMPHETAMINE QUANT,4080442,CDM,300,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
PLT AGGRN -ARISTOCETIN EA (PLAVIX),4080443,CDM,305,RC,85576,HCPCS,Outpatient,,,102.15,61.29,,88.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges,76.61,75,,,percent of total billed charges,75% of total billed charges,44.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.18,350,,,Fee Schedule,350% of CMS OPPS Rate,25.4,102,,,Fee Schedule,102% of CMS OPPS Rate,78.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,23.87,100,,,Fee Schedule,100% of UHC Fee Schedule,71.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,57.29,230,,,Fee Schedule,230% of CMS OPPS Rate,49.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.35,91.94,
"GARDNERELLA V, DNA, RNA  AGENT",4080444,CDM,300,RC,87512,HCPCS,Outpatient,,,208,124.8,,147.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.6,70,,,percent of total billed charges,70% of total billed charges,156,75,,,percent of total billed charges,75% of total billed charges,75.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.16,350,,,Fee Schedule,350% of CMS OPPS Rate,42.59,102,,,Fee Schedule,102% of CMS OPPS Rate,159.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.4,100,,,Fee Schedule,100% of UHC Fee Schedule,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,96.04,230,,,Fee Schedule,230% of CMS OPPS Rate,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,187.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,24.93,187.2,
PRIMIDONE,4080445,CDM,301,RC,80188,HCPCS,Outpatient,,,138.15,82.89,,58.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.71,70,,,percent of total billed charges,70% of total billed charges,103.61,75,,,percent of total billed charges,75% of total billed charges,29.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.06,350,,,Fee Schedule,350% of CMS OPPS Rate,16.92,102,,,Fee Schedule,102% of CMS OPPS Rate,105.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,62.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of UHC Fee Schedule,96.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,230,,,Fee Schedule,230% of CMS OPPS Rate,66.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,124.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,124.34,
PHENOBARBITAL SERUM,4080445,CDM,301,RC,80184,HCPCS,Outpatient,,,167.4,100.44,,54.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges,125.55,75,,,percent of total billed charges,75% of total billed charges,27.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,133.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.55,350,,,Fee Schedule,350% of CMS OPPS Rate,15.6,102,,,Fee Schedule,102% of CMS OPPS Rate,128.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,100,,,Fee Schedule,100% of UHC Fee Schedule,117.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.19,230,,,Fee Schedule,230% of CMS OPPS Rate,80.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,150.66,
DRUG TEST DEFINITIVE 1-7 CLASSES,4080446,CDM,300,RC,80377,HCPCS,Outpatient,,,230,138,,,,,,Other,Not Separately reimbursable,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,161,70,,,percent of total billed charges,70% of total billed charges,172.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.04,207,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4080447,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
MICROSOMAL AB,4080447,CDM,302,RC,86376,HCPCS,Outpatient,,,95.7,57.42,,51.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,26.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.92,350,,,Fee Schedule,350% of CMS OPPS Rate,14.84,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,86.13,
FLORESCENT CHEM ABS,4080447,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
ANA(REFLEX TITER),4080447,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
AMIODARONE,4080448,CDM,301,RC,80151,HCPCS,Outpatient,,,94,56.4,,65.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47,50,,,percent of total billed charges,pays at 50% of total billed charges,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,33.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.24,350,,,Fee Schedule,350% of CMS OPPS Rate,19.01,102,,,Fee Schedule,102% of CMS OPPS Rate,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.87,230,,,Fee Schedule,230% of CMS OPPS Rate,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,84.6,
SM(SMITH) IGG ABS,4080449,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
PROTEIN WESTERN BLOT,4080449,CDM,301,RC,84182,HCPCS,Outpatient,,,88,52.8,,103.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,59.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,52.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.23,350,,,Fee Schedule,350% of CMS OPPS Rate,29.79,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,26.29,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,67.18,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,103.4,
CLINICAL PATHOLOGY CONSULT,4080500,CDM,302,RC,80500,HCPCS,Outpatient,,,630,378,,,,,,Other,Not Separately reimbursable,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.23,567,
FELBAMATE,4080501,CDM,301,RC,80167,HCPCS,Outpatient,,,94,56.4,,65.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47,50,,,percent of total billed charges,pays at 50% of total billed charges,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,33.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.24,350,,,Fee Schedule,350% of CMS OPPS Rate,19.01,102,,,Fee Schedule,102% of CMS OPPS Rate,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.87,230,,,Fee Schedule,230% of CMS OPPS Rate,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,84.6,
"INFECTIOUS A. DNA, QUANT",4080502,CDM,300,RC,87799,HCPCS,Outpatient,,,245.85,147.51,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,172.1,70,,,percent of total billed charges,70% of total billed charges,184.39,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,196.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,188.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,110.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,172.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,118.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,221.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,16.7,221.27,
Blood test for an STD,4080502,CDM,306,RC,87591,HCPCS,Outpatient,,,185.4,111.24,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges,139.05,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,141.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,88.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,166.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,166.86,
Blood test for an STD,4080502,CDM,306,RC,87661,HCPCS,Outpatient,,,280,168,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,252,
CANDIDA  SPECIES AMPLFD PROBE TECH,4080502,CDM,306,RC,87481,HCPCS,Outpatient,,,240.7,144.42,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.49,70,,,percent of total billed charges,70% of total billed charges,180.53,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,184.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,108.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,168.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,115.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,216.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,216.63,
"GARDNERELLA V, DNA, RNA  AGENT",4080502,CDM,300,RC,87512,HCPCS,Outpatient,,,208,124.8,,147.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.6,70,,,percent of total billed charges,70% of total billed charges,156,75,,,percent of total billed charges,75% of total billed charges,75.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.16,350,,,Fee Schedule,350% of CMS OPPS Rate,42.59,102,,,Fee Schedule,102% of CMS OPPS Rate,159.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,93.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.4,100,,,Fee Schedule,100% of UHC Fee Schedule,145.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,96.04,230,,,Fee Schedule,230% of CMS OPPS Rate,99.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,187.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,24.93,187.2,
Test that detects Chlamydia,4080502,CDM,300,RC,87491,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
LACOSAMIDE,4080503,CDM,301,RC,80235,HCPCS,Outpatient,,,386,231.6,,95.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,193,50,,,percent of total billed charges,pays at 50% of total billed charges,270.2,70,,,percent of total billed charges,70% of total billed charges,289.5,75,,,percent of total billed charges,75% of total billed charges,48.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,308.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.88,350,,,Fee Schedule,350% of CMS OPPS Rate,27.65,102,,,Fee Schedule,102% of CMS OPPS Rate,295.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,173.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,270.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,231.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,100,,,Fee Schedule,100% of UHC Fee Schedule,270.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,62.35,230,,,Fee Schedule,230% of CMS OPPS Rate,185.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,347.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.98,347.4,
ITRACONAZOLE,4080504,CDM,301,RC,80189,HCPCS,Outpatient,,,350,210,,95.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,175,50,,,percent of total billed charges,pays at 50% of total billed charges,245,70,,,percent of total billed charges,70% of total billed charges,262.5,75,,,percent of total billed charges,75% of total billed charges,48.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.88,350,,,Fee Schedule,350% of CMS OPPS Rate,27.65,102,,,Fee Schedule,102% of CMS OPPS Rate,267.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,157.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,175,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,62.35,230,,,Fee Schedule,230% of CMS OPPS Rate,168,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,315,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.33,315,
VORICONAZOLE,4080505,CDM,300,RC,80285,HCPCS,Outpatient,,,332,199.2,,95.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,166,50,,,percent of total billed charges,pays at 50% of total billed charges,232.4,70,,,percent of total billed charges,70% of total billed charges,249,75,,,percent of total billed charges,75% of total billed charges,48.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.88,350,,,Fee Schedule,350% of CMS OPPS Rate,27.65,102,,,Fee Schedule,102% of CMS OPPS Rate,253.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,149.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,232.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,100,,,Fee Schedule,100% of UHC Fee Schedule,232.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,62.35,230,,,Fee Schedule,230% of CMS OPPS Rate,159.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,298.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.98,298.8,
IMMUNOGLOBULIN LIGHT CHAINS FREE EA,4080506,CDM,300,RC,83521,HCPCS,Outpatient,,,216,129.6,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,108,50,,,percent of total billed charges,pays at 50% of total billed charges,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,194.4,
URINALYSIS-MICRO ONLY,4081015,CDM,307,RC,81015,HCPCS,Outpatient,,,78.3,46.98,,10.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.81,70,,,percent of total billed charges,70% of total billed charges,58.73,75,,,percent of total billed charges,75% of total billed charges,5.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.67,350,,,Fee Schedule,350% of CMS OPPS Rate,3.11,102,,,Fee Schedule,102% of CMS OPPS Rate,59.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,35.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,100,,,Fee Schedule,100% of UHC Fee Schedule,54.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,230,,,Fee Schedule,230% of CMS OPPS Rate,37.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,70.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,70.47,
IDH1 COMMON VARIANTS,4081120,CDM,310,RC,81120,HCPCS,Outpatient,,,483,289.8,,684.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,193.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,394.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,338.1,70,,,percent of total billed charges,70% of total billed charges,362.25,75,,,percent of total billed charges,75% of total billed charges,347.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,386.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.37,350,,,Fee Schedule,350% of CMS OPPS Rate,197.11,102,,,Fee Schedule,102% of CMS OPPS Rate,369.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,217.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,338.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,289.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of UHC Fee Schedule,338.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,444.47,230,,,Fee Schedule,230% of CMS OPPS Rate,231.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,434.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,75.69,684.1,
IDH2 COMMON VARIANTS,4081121,CDM,310,RC,81121,HCPCS,Outpatient,,,740,444,,1047.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,295.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,603.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,518,70,,,percent of total billed charges,70% of total billed charges,555,75,,,percent of total billed charges,75% of total billed charges,532.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,592,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1035.26,350,,,Fee Schedule,350% of CMS OPPS Rate,301.7,102,,,Fee Schedule,102% of CMS OPPS Rate,566.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,127.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,333,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,518,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,444,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,266.21,100,,,Fee Schedule,100% of UHC Fee Schedule,518,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,680.31,230,,,Fee Schedule,230% of CMS OPPS Rate,355.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,666,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,295.79,100,,,Fee Schedule,100% of CMS OPPS Rate,115.96,1047.09,
DYSTROPHIN DELETION ANAL.,4081161,CDM,310,RC,81161,HCPCS,Outpatient,,,697.5,418.5,,987.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,279,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,568.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,488.25,70,,,percent of total billed charges,70% of total billed charges,523.13,75,,,percent of total billed charges,75% of total billed charges,502.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,558,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,976.5,350,,,Fee Schedule,350% of CMS OPPS Rate,284.58,102,,,Fee Schedule,102% of CMS OPPS Rate,533.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,313.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,488.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,279,100,,,Fee Schedule,100% of CMS OPPS Rate,251.1,100,,,Fee Schedule,100% of UHC Fee Schedule,488.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279,100,,,Fee Schedule,100% of CMS OPPS Rate,641.7,230,,,Fee Schedule,230% of CMS OPPS Rate,334.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,279,100,,,Fee Schedule,100% of CMS OPPS Rate,627.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,279,100,,,Fee Schedule,100% of CMS OPPS Rate,109.3,987.66,
"BRCA1, BRCA2 FULL SEQUENCE ANALYSIS",4081162,CDM,310,RC,81162,HCPCS,Outpatient,,,5632.33,3379.4,,6460.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1824.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1824.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4593.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3942.63,70,,,percent of total billed charges,70% of total billed charges,4224.25,75,,,percent of total billed charges,75% of total billed charges,3284.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4505.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6387.08,350,,,Fee Schedule,350% of CMS OPPS Rate,1861.37,102,,,Fee Schedule,102% of CMS OPPS Rate,4308.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2534.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3942.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3379.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2027.64,100,,,Fee Schedule,100% of UHC Fee Schedule,3942.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,4197.22,230,,,Fee Schedule,230% of CMS OPPS Rate,2703.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,5069.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.88,6460.07,
ABL 1 PROTO ONCOGENE 1,4081170,CDM,300,RC,81170,HCPCS,Outpatient,,,829.55,497.73,,1062,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,300,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,300,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,611.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,580.69,70,,,percent of total billed charges,70% of total billed charges,622.16,75,,,percent of total billed charges,75% of total billed charges,540,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,663.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1050,350,,,Fee Schedule,350% of CMS OPPS Rate,306,102,,,Fee Schedule,102% of CMS OPPS Rate,634.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,373.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,580.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,497.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,300,100,,,Fee Schedule,100% of CMS OPPS Rate,270,100,,,Fee Schedule,100% of UHC Fee Schedule,580.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300,100,,,Fee Schedule,100% of CMS OPPS Rate,690,230,,,Fee Schedule,230% of CMS OPPS Rate,398.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,Fee Schedule,100% of CMS OPPS Rate,746.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,300,100,,,Fee Schedule,100% of CMS OPPS Rate,232.2,1062,
BCR/ABL1 CHRONIC MYELO LEUKEMIA,4081206,CDM,300,RC,81206,HCPCS,Outpatient,,,700,420,,580.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,163.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,412.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,295.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.86,350,,,Fee Schedule,350% of CMS OPPS Rate,167.23,102,,,Fee Schedule,102% of CMS OPPS Rate,535.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,315,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,182.18,100,,,Fee Schedule,100% of UHC Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,377.1,230,,,Fee Schedule,230% of CMS OPPS Rate,336,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,630,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,141.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,163.96,100,,,Fee Schedule,100% of CMS OPPS Rate,141.01,630,
BCR ALB1 ANALYSIS,4081207,CDM,300,RC,81207,HCPCS,Outpatient,,,768,460.8,,512.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,124.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,144.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,144.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,364.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,537.6,70,,,percent of total billed charges,70% of total billed charges,576,75,,,percent of total billed charges,75% of total billed charges,260.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,614.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.94,350,,,Fee Schedule,350% of CMS OPPS Rate,147.73,102,,,Fee Schedule,102% of CMS OPPS Rate,587.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,345.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,537.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,160.93,100,,,Fee Schedule,100% of UHC Fee Schedule,537.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,333.13,230,,,Fee Schedule,230% of CMS OPPS Rate,368.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,691.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,124.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,100,,,Fee Schedule,100% of CMS OPPS Rate,124.56,691.2,
BRAF (B-RAF PROTO ONCOGENE VIRUS B1),4081210,CDM,310,RC,81210,HCPCS,Outpatient,,,896,537.6,,620.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,175.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,357.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,627.2,70,,,percent of total billed charges,70% of total billed charges,672,75,,,percent of total billed charges,75% of total billed charges,315.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,716.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,613.9,350,,,Fee Schedule,350% of CMS OPPS Rate,178.9,102,,,Fee Schedule,102% of CMS OPPS Rate,685.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,403.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,627.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,537.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,157.86,100,,,Fee Schedule,100% of UHC Fee Schedule,627.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,403.42,230,,,Fee Schedule,230% of CMS OPPS Rate,430.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,806.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,140.4,806.4,
"BRCA1, BRCA2 BREAST CANCER 1 AND 2",4081212,CDM,310,RC,81212,HCPCS,Outpatient,,,1000,600,,1557.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,170.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,440,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,440,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,897.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,700,70,,,percent of total billed charges,70% of total billed charges,750,75,,,percent of total billed charges,75% of total billed charges,792,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1540,350,,,Fee Schedule,350% of CMS OPPS Rate,448.8,102,,,Fee Schedule,102% of CMS OPPS Rate,765,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,450,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,440,100,,,Fee Schedule,100% of CMS OPPS Rate,396,100,,,Fee Schedule,100% of UHC Fee Schedule,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440,100,,,Fee Schedule,100% of CMS OPPS Rate,1000,230,,,Fee Schedule,230% of CMS OPPS Rate,480,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,440,100,,,Fee Schedule,100% of CMS OPPS Rate,900,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,440,100,,,Fee Schedule,100% of CMS OPPS Rate,170.92,1557.6,
CALRETICULIN GENE ANALYSIS,4081219,CDM,300,RC,81219,HCPCS,Outpatient,,,834.2,500.52,,430.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,306.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,583.94,70,,,percent of total billed charges,70% of total billed charges,625.65,75,,,percent of total billed charges,75% of total billed charges,218.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,667.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.7,350,,,Fee Schedule,350% of CMS OPPS Rate,124.06,102,,,Fee Schedule,102% of CMS OPPS Rate,638.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,375.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,135.14,100,,,Fee Schedule,100% of UHC Fee Schedule,583.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,279.74,230,,,Fee Schedule,230% of CMS OPPS Rate,400.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,750.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,100,,,Fee Schedule,100% of CMS OPPS Rate,121.63,750.78,
CFTR CYSTIC FIBROSIS GENE ANALYSIS,4081220,CDM,300,RC,81220,HCPCS,Outpatient,,,1908,1144.8,,1970.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,289.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,556.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,556.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1134.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1335.6,70,,,percent of total billed charges,70% of total billed charges,1431,75,,,percent of total billed charges,75% of total billed charges,1001.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1526.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1948.1,350,,,Fee Schedule,350% of CMS OPPS Rate,567.73,102,,,Fee Schedule,102% of CMS OPPS Rate,1459.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,858.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1335.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1144.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,500.94,100,,,Fee Schedule,100% of UHC Fee Schedule,1335.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1280.18,230,,,Fee Schedule,230% of CMS OPPS Rate,915.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1717.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,556.6,100,,,Fee Schedule,100% of CMS OPPS Rate,289.36,1970.36,
CFTR DUPLICATION /DELETION VARIANT,4081222,CDM,310,RC,81222,HCPCS,Outpatient,,,1088,652.8,,1540.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,435.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,887.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,761.6,70,,,percent of total billed charges,70% of total billed charges,816,75,,,percent of total billed charges,75% of total billed charges,783.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,870.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1522.74,350,,,Fee Schedule,350% of CMS OPPS Rate,443.77,102,,,Fee Schedule,102% of CMS OPPS Rate,832.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,489.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,761.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,391.56,100,,,Fee Schedule,100% of UHC Fee Schedule,761.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1000.66,230,,,Fee Schedule,230% of CMS OPPS Rate,522.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,979.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,435.07,100,,,Fee Schedule,100% of CMS OPPS Rate,170.49,1540.14,
CFTR FULL GENE SEQUENCE,4081223,CDM,310,RC,81233,HCPCS,Outpatient,,,1248,748.8,,620.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,175.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,357.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,873.6,70,,,percent of total billed charges,70% of total billed charges,936,75,,,percent of total billed charges,75% of total billed charges,315.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,613.9,350,,,Fee Schedule,350% of CMS OPPS Rate,178.9,102,,,Fee Schedule,102% of CMS OPPS Rate,954.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,215.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,561.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,157.86,100,,,Fee Schedule,100% of UHC Fee Schedule,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,403.42,230,,,Fee Schedule,230% of CMS OPPS Rate,599.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,175.4,100,,,Fee Schedule,100% of CMS OPPS Rate,157.86,1123.2,
CYTOGENETICS MICRO ARRAY ANALYSIS,4081228,CDM,300,RC,81228,HCPCS,Outpatient,,,3164,1898.4,,3186,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,900,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,900,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1835.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2214.8,70,,,percent of total billed charges,70% of total billed charges,2373,75,,,percent of total billed charges,75% of total billed charges,1620,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3150,350,,,Fee Schedule,350% of CMS OPPS Rate,918,102,,,Fee Schedule,102% of CMS OPPS Rate,2420.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,545.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2214.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1898.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,900,100,,,Fee Schedule,100% of CMS OPPS Rate,810,100,,,Fee Schedule,100% of UHC Fee Schedule,2214.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,900,100,,,Fee Schedule,100% of CMS OPPS Rate,2070,230,,,Fee Schedule,230% of CMS OPPS Rate,1518.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,900,100,,,Fee Schedule,100% of CMS OPPS Rate,2847.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,495.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,900,100,,,Fee Schedule,100% of CMS OPPS Rate,495.8,3186,
CYTOGENOMIC C MICROARRAY,4081229,CDM,300,RC,81229,HCPCS,Outpatient,,,3480,2088,,4106.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,185.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1160,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1160,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2365.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2436,70,,,percent of total billed charges,70% of total billed charges,2610,75,,,percent of total billed charges,75% of total billed charges,2088,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4060,350,,,Fee Schedule,350% of CMS OPPS Rate,1183.2,102,,,Fee Schedule,102% of CMS OPPS Rate,2662.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1566,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2436,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2088,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1044,100,,,Fee Schedule,100% of UHC Fee Schedule,2436,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,2668,230,,,Fee Schedule,230% of CMS OPPS Rate,1670.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,3132,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,1160,100,,,Fee Schedule,100% of CMS OPPS Rate,185.03,4106.4,
DIHYDROPYRIMIDINE D. GENE VARIENT,4081232,CDM,310,RC,81232,HCPCS,Outpatient,,,874,524.4,,618.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,356.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,611.8,70,,,percent of total billed charges,70% of total billed charges,655.5,75,,,percent of total billed charges,75% of total billed charges,314.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,699.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,611.83,350,,,Fee Schedule,350% of CMS OPPS Rate,178.3,102,,,Fee Schedule,102% of CMS OPPS Rate,668.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,150.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,393.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,611.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,524.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,157.33,100,,,Fee Schedule,100% of UHC Fee Schedule,611.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,402.06,230,,,Fee Schedule,230% of CMS OPPS Rate,419.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,786.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,174.81,100,,,Fee Schedule,100% of CMS OPPS Rate,136.96,786.6,
EGFR (EPIDERMAL GROWTH FACTOR R),4081235,CDM,300,RC,81235,HCPCS,Outpatient,,,1253,751.8,,1149.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,251.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,324.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,324.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,661.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,877.1,70,,,percent of total billed charges,70% of total billed charges,939.75,75,,,percent of total billed charges,75% of total billed charges,584.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1002.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1136.03,350,,,Fee Schedule,350% of CMS OPPS Rate,331.07,102,,,Fee Schedule,102% of CMS OPPS Rate,958.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,563.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,877.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,751.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,292.12,100,,,Fee Schedule,100% of UHC Fee Schedule,877.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,746.53,230,,,Fee Schedule,230% of CMS OPPS Rate,601.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1127.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,251.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,251.23,1149.01,
F2 PROTHROMBIN COAG FACTOR 2,4081240,CDM,300,RC,81240,HCPCS,Outpatient,,,294,176.4,,232.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,133.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.8,70,,,percent of total billed charges,70% of total billed charges,220.5,75,,,percent of total billed charges,75% of total billed charges,118.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,229.91,350,,,Fee Schedule,350% of CMS OPPS Rate,67,102,,,Fee Schedule,102% of CMS OPPS Rate,224.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,132.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,59.12,100,,,Fee Schedule,100% of UHC Fee Schedule,205.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,151.08,230,,,Fee Schedule,230% of CMS OPPS Rate,141.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,65.69,100,,,Fee Schedule,100% of CMS OPPS Rate,46.07,264.6,
F5 COAGULATION FACTOR V,4081241,CDM,300,RC,81241,HCPCS,Outpatient,,,294,176.4,,259.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,55.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,153.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.8,70,,,percent of total billed charges,70% of total billed charges,220.5,75,,,percent of total billed charges,75% of total billed charges,132.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,235.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,256.79,350,,,Fee Schedule,350% of CMS OPPS Rate,74.83,102,,,Fee Schedule,102% of CMS OPPS Rate,224.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,132.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,67.9,100,,,Fee Schedule,100% of UHC Fee Schedule,205.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,168.75,230,,,Fee Schedule,230% of CMS OPPS Rate,141.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,73.37,100,,,Fee Schedule,100% of CMS OPPS Rate,55.03,264.6,
FMR1 FRAGILE X MENTAL R GENE,4081243,CDM,310,RC,81243,HCPCS,Outpatient,,,303,181.8,,201.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,102.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.64,350,,,Fee Schedule,350% of CMS OPPS Rate,58.18,102,,,Fee Schedule,102% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,51.34,100,,,Fee Schedule,100% of UHC Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,131.19,230,,,Fee Schedule,230% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,57.04,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,272.7,
FMR1 FRAGILE X M R EXPANDED SIZE,4081244,CDM,310,RC,81244,HCPCS,Outpatient,,,303,181.8,,158.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.53,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,80.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,157.11,350,,,Fee Schedule,350% of CMS OPPS Rate,45.78,102,,,Fee Schedule,102% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,40.4,100,,,Fee Schedule,100% of UHC Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,103.24,230,,,Fee Schedule,230% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,44.89,100,,,Fee Schedule,100% of CMS OPPS Rate,40.4,272.7,
G6PD CATALYTIC SUBUNIT,4081250,CDM,310,RC,81250,HCPCS,Outpatient,,,598,358.8,,207.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,58.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,119.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,418.6,70,,,percent of total billed charges,70% of total billed charges,448.5,75,,,percent of total billed charges,75% of total billed charges,105.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,478.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204.71,350,,,Fee Schedule,350% of CMS OPPS Rate,59.65,102,,,Fee Schedule,102% of CMS OPPS Rate,457.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,269.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,418.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,52.64,100,,,Fee Schedule,100% of UHC Fee Schedule,418.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,134.52,230,,,Fee Schedule,230% of CMS OPPS Rate,287.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,538.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,58.49,100,,,Fee Schedule,100% of CMS OPPS Rate,52.64,538.2,
HEXA  A TAY SACHS DESEASE,4081255,CDM,310,RC,81255,HCPCS,Outpatient,,,270,162,,182.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,189,70,,,percent of total billed charges,70% of total billed charges,202.5,75,,,percent of total billed charges,75% of total billed charges,92.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.07,350,,,Fee Schedule,350% of CMS OPPS Rate,52.47,102,,,Fee Schedule,102% of CMS OPPS Rate,206.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,121.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of UHC Fee Schedule,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,118.33,230,,,Fee Schedule,230% of CMS OPPS Rate,129.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,243,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,51.45,100,,,Fee Schedule,100% of CMS OPPS Rate,42.31,243,
HFE HEMOCHROMATOSIS GENE ANAL,4081256,CDM,300,RC,81256,HCPCS,Outpatient,,,424,254.4,,231.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,296.8,70,,,percent of total billed charges,70% of total billed charges,318,75,,,percent of total billed charges,75% of total billed charges,117.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.76,350,,,Fee Schedule,350% of CMS OPPS Rate,66.66,102,,,Fee Schedule,102% of CMS OPPS Rate,324.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,72.62,100,,,Fee Schedule,100% of UHC Fee Schedule,296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,150.32,230,,,Fee Schedule,230% of CMS OPPS Rate,203.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.36,381.6,
HBA1/ HBA2 ALPHA GLOBIN 1 AND 2,4081257,CDM,310,RC,81257,HCPCS,Outpatient,,,920,552,,362,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,102.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,208.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,644,70,,,percent of total billed charges,70% of total billed charges,690,75,,,percent of total billed charges,75% of total billed charges,184.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,357.91,350,,,Fee Schedule,350% of CMS OPPS Rate,104.3,102,,,Fee Schedule,102% of CMS OPPS Rate,703.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,414,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,552,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,92.03,100,,,Fee Schedule,100% of UHC Fee Schedule,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,235.19,230,,,Fee Schedule,230% of CMS OPPS Rate,441.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,828,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,102.26,100,,,Fee Schedule,100% of CMS OPPS Rate,92.03,828,
B CELL (IGH GENE REARRANGEMENT),4081261,CDM,301,RC,81261,HCPCS,Outpatient,,,700,420,,700.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,197.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,356.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,692.96,350,,,Fee Schedule,350% of CMS OPPS Rate,201.94,102,,,Fee Schedule,102% of CMS OPPS Rate,535.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,315,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,219.99,100,,,Fee Schedule,100% of UHC Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,455.37,230,,,Fee Schedule,230% of CMS OPPS Rate,336,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,630,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,197.99,100,,,Fee Schedule,100% of CMS OPPS Rate,109.69,700.88,
IGH MUTATION ANALYSIS,4081263,CDM,300,RC,81263,HCPCS,Outpatient,,,736.3,441.78,,1042.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,741.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,515.41,70,,,percent of total billed charges,70% of total billed charges,552.23,75,,,percent of total billed charges,75% of total billed charges,530.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,589.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1030.82,350,,,Fee Schedule,350% of CMS OPPS Rate,300.41,102,,,Fee Schedule,102% of CMS OPPS Rate,563.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,331.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,515.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,327.24,100,,,Fee Schedule,100% of UHC Fee Schedule,515.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,677.39,230,,,Fee Schedule,230% of CMS OPPS Rate,353.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,662.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,294.52,100,,,Fee Schedule,100% of CMS OPPS Rate,115.38,1042.6,
IGK KAPPA LIGHT CHAIN LOCUS,4081264,CDM,310,RC,81264,HCPCS,Outpatient,,,862,517.2,,611.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,375.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,603.4,70,,,percent of total billed charges,70% of total billed charges,646.5,75,,,percent of total billed charges,75% of total billed charges,310.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,689.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,604.55,350,,,Fee Schedule,350% of CMS OPPS Rate,176.18,102,,,Fee Schedule,102% of CMS OPPS Rate,659.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,148.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,387.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,603.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,517.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,165.92,100,,,Fee Schedule,100% of UHC Fee Schedule,603.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,397.27,230,,,Fee Schedule,230% of CMS OPPS Rate,413.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,775.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,172.73,100,,,Fee Schedule,100% of CMS OPPS Rate,135.08,775.8,
HBA1/HBA2 ALPHA GLOBIN GENE ANALYSIS,4081269,CDM,310,RC,81269,HCPCS,Outpatient,,,1187.34,712.4,,716.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,412.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,831.14,70,,,percent of total billed charges,70% of total billed charges,890.51,75,,,percent of total billed charges,75% of total billed charges,364.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,949.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,708.4,350,,,Fee Schedule,350% of CMS OPPS Rate,206.44,102,,,Fee Schedule,102% of CMS OPPS Rate,908.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,204.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,534.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,831.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,182.16,100,,,Fee Schedule,100% of UHC Fee Schedule,831.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,465.52,230,,,Fee Schedule,230% of CMS OPPS Rate,569.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,202.4,100,,,Fee Schedule,100% of CMS OPPS Rate,182.16,1068.61,
JAK2 GENE ANALYSIS VA1617PHE,4081270,CDM,300,RC,81270,HCPCS,Outpatient,,,500,300,,324.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,230.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,350,70,,,percent of total billed charges,70% of total billed charges,375,75,,,percent of total billed charges,75% of total billed charges,164.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.81,350,,,Fee Schedule,350% of CMS OPPS Rate,93.49,102,,,Fee Schedule,102% of CMS OPPS Rate,382.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,225,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,101.85,100,,,Fee Schedule,100% of UHC Fee Schedule,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,210.81,230,,,Fee Schedule,230% of CMS OPPS Rate,240,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,450,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,91.66,100,,,Fee Schedule,100% of CMS OPPS Rate,78.35,450,
HUNTINGTON DISEASE GENE ANALYSIS,4081271,CDM,310,RC,81271,HCPCS,Outpatient,,,696,417.6,,484.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,137,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,279.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,487.2,70,,,percent of total billed charges,70% of total billed charges,522,75,,,percent of total billed charges,75% of total billed charges,246.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,556.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,479.5,350,,,Fee Schedule,350% of CMS OPPS Rate,139.74,102,,,Fee Schedule,102% of CMS OPPS Rate,532.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,313.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,417.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,123.3,100,,,Fee Schedule,100% of UHC Fee Schedule,487.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,315.1,230,,,Fee Schedule,230% of CMS OPPS Rate,334.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,626.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,109.06,626.4,
GENE ANALYSIS D816 VARIANT,4081273,CDM,310,RC,81273,HCPCS,Outpatient,,,504.9,302.94,,442.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,124.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges,378.68,75,,,percent of total billed charges,75% of total billed charges,224.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,403.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,437.04,350,,,Fee Schedule,350% of CMS OPPS Rate,127.36,102,,,Fee Schedule,102% of CMS OPPS Rate,386.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,227.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,112.38,100,,,Fee Schedule,100% of UHC Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,287.2,230,,,Fee Schedule,230% of CMS OPPS Rate,242.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,454.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,124.87,100,,,Fee Schedule,100% of CMS OPPS Rate,79.12,454.41,
KRAS GENE VARIANTS EXON 2,4081275,CDM,300,RC,81275,HCPCS,Outpatient,,,634.64,380.78,,684.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,149.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,193.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,193.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,394.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,444.25,70,,,percent of total billed charges,70% of total billed charges,475.98,75,,,percent of total billed charges,75% of total billed charges,347.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,507.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.37,350,,,Fee Schedule,350% of CMS OPPS Rate,197.11,102,,,Fee Schedule,102% of CMS OPPS Rate,485.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,285.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,444.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,380.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of UHC Fee Schedule,444.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,444.47,230,,,Fee Schedule,230% of CMS OPPS Rate,304.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,571.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,149.58,684.1,
KRAS GENE ANALYSIS ADDTL VAR,4081276,CDM,310,RC,81276,HCPCS,Outpatient,,,985.96,591.58,,684.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,149.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,193.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,193.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,394.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,690.17,70,,,percent of total billed charges,70% of total billed charges,739.47,75,,,percent of total billed charges,75% of total billed charges,347.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,788.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,676.37,350,,,Fee Schedule,350% of CMS OPPS Rate,197.11,102,,,Fee Schedule,102% of CMS OPPS Rate,754.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,443.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,690.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,591.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of UHC Fee Schedule,690.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,444.47,230,,,Fee Schedule,230% of CMS OPPS Rate,473.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,887.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,193.25,100,,,Fee Schedule,100% of CMS OPPS Rate,149.58,887.36,
MTHFR GENE ANALYSIS,4081291,CDM,300,RC,81291,HCPCS,Outpatient,,,344,206.4,,231.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,133.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,258,75,,,percent of total billed charges,75% of total billed charges,117.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,275.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,228.69,350,,,Fee Schedule,350% of CMS OPPS Rate,66.64,102,,,Fee Schedule,102% of CMS OPPS Rate,263.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,154.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,240.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,58.81,100,,,Fee Schedule,100% of UHC Fee Schedule,240.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,150.28,230,,,Fee Schedule,230% of CMS OPPS Rate,165.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,309.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,65.34,100,,,Fee Schedule,100% of CMS OPPS Rate,53.9,309.6,
MICROSATELLITE INSTABILITY ANALYSIS,4081301,CDM,310,RC,81301,HCPCS,Outpatient,,,1970.25,1182.15,,1233.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,348.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,728.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1379.18,70,,,percent of total billed charges,70% of total billed charges,1477.69,75,,,percent of total billed charges,75% of total billed charges,627.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1576.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1219.96,350,,,Fee Schedule,350% of CMS OPPS Rate,355.53,102,,,Fee Schedule,102% of CMS OPPS Rate,1507.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,339.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,886.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1379.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1182.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,321.73,100,,,Fee Schedule,100% of UHC Fee Schedule,1379.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,801.68,230,,,Fee Schedule,230% of CMS OPPS Rate,945.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1773.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,308.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,348.56,100,,,Fee Schedule,100% of CMS OPPS Rate,308.74,1773.23,
PCA3/KLK3 (PROSTATE CANCER ANTIGEN 3),4081313,CDM,310,RC,81313,HCPCS,Outpatient,,,1275.25,765.15,,902.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,520.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,892.68,70,,,percent of total billed charges,70% of total billed charges,956.44,75,,,percent of total billed charges,75% of total billed charges,459.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1020.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,892.67,350,,,Fee Schedule,350% of CMS OPPS Rate,260.15,102,,,Fee Schedule,102% of CMS OPPS Rate,975.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,219.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,573.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,892.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,765.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,229.55,100,,,Fee Schedule,100% of UHC Fee Schedule,892.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,586.61,230,,,Fee Schedule,230% of CMS OPPS Rate,612.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1147.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,255.05,100,,,Fee Schedule,100% of CMS OPPS Rate,199.83,1147.73,
PDGFRA RECEPTOR GEN ANALYSIS,4081314,CDM,310,RC,81314,HCPCS,Outpatient,,,1648,988.8,,1166.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,329.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,671.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1153.6,70,,,percent of total billed charges,70% of total billed charges,1236,75,,,percent of total billed charges,75% of total billed charges,593.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1318.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1153.28,350,,,Fee Schedule,350% of CMS OPPS Rate,336.1,102,,,Fee Schedule,102% of CMS OPPS Rate,1260.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,283.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,741.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,988.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,296.56,100,,,Fee Schedule,100% of UHC Fee Schedule,1153.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,757.87,230,,,Fee Schedule,230% of CMS OPPS Rate,791.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1483.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,329.51,100,,,Fee Schedule,100% of CMS OPPS Rate,258.24,1483.2,
PML RARALPHA T 15 17,4081315,CDM,310,RC,81315,HCPCS,Outpatient,,,1414,848.4,,733.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,207.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,521.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,989.8,70,,,percent of total billed charges,70% of total billed charges,1060.5,75,,,percent of total billed charges,75% of total billed charges,373.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,725.58,350,,,Fee Schedule,350% of CMS OPPS Rate,211.45,102,,,Fee Schedule,102% of CMS OPPS Rate,1081.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,243.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,636.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,989.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,848.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,230.35,100,,,Fee Schedule,100% of UHC Fee Schedule,989.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,476.81,230,,,Fee Schedule,230% of CMS OPPS Rate,678.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,221.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,100,,,Fee Schedule,100% of CMS OPPS Rate,207.31,1272.6,
PMP22 GENE ANALYSIS,4081325,CDM,310,RC,81325,HCPCS,Outpatient,,,1924,1154.4,,2724.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,769.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1569.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1346.8,70,,,percent of total billed charges,70% of total billed charges,1443,75,,,percent of total billed charges,75% of total billed charges,1385.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2693.53,350,,,Fee Schedule,350% of CMS OPPS Rate,784.97,102,,,Fee Schedule,102% of CMS OPPS Rate,1471.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,331.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,865.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1346.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1154.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,692.62,100,,,Fee Schedule,100% of UHC Fee Schedule,1346.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1770.03,230,,,Fee Schedule,230% of CMS OPPS Rate,923.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,769.58,100,,,Fee Schedule,100% of CMS OPPS Rate,301.49,2724.31,
GENE ANALYSIS SMN1,4081329,CDM,310,RC,81329,HCPCS,Outpatient,,,1310,786,,484.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,137,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,279.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,917,70,,,percent of total billed charges,70% of total billed charges,982.5,75,,,percent of total billed charges,75% of total billed charges,246.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1048,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,479.5,350,,,Fee Schedule,350% of CMS OPPS Rate,139.74,102,,,Fee Schedule,102% of CMS OPPS Rate,1002.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,225.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,589.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,917,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,786,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,123.3,100,,,Fee Schedule,100% of UHC Fee Schedule,917,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,315.1,230,,,Fee Schedule,230% of CMS OPPS Rate,628.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,1179,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,123.3,1179,
SNR PN/UBE3A PRADER WILLI SYNDROME,4081331,CDM,310,RC,81331,HCPCS,Outpatient,,,525,315,,180.78,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,367.5,70,,,percent of total billed charges,70% of total billed charges,393.75,75,,,percent of total billed charges,75% of total billed charges,91.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.74,350,,,Fee Schedule,350% of CMS OPPS Rate,52.09,102,,,Fee Schedule,102% of CMS OPPS Rate,401.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45.96,100,,,Fee Schedule,100% of UHC Fee Schedule,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,117.46,230,,,Fee Schedule,230% of CMS OPPS Rate,252,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45.96,472.5,
ALPHA 1 ANTITRYPSIN GENE ANALYSIS,4081332,CDM,310,RC,81332,HCPCS,Outpatient,,,550,330,,154.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,109.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,385,70,,,percent of total billed charges,70% of total billed charges,412.5,75,,,percent of total billed charges,75% of total billed charges,78.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.77,350,,,Fee Schedule,350% of CMS OPPS Rate,44.52,102,,,Fee Schedule,102% of CMS OPPS Rate,420.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,48.5,100,,,Fee Schedule,100% of UHC Fee Schedule,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,100.39,230,,,Fee Schedule,230% of CMS OPPS Rate,264,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,495,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,495,
MPL PROTO ONCOGENE T. RECEPTOR,4081339,CDM,310,RC,81339,HCPCS,Outpatient,,,926,555.6,,655.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,138.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,185.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,185.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,463,50,,,percent of total billed charges,pays at 50% of total billed charges,648.2,70,,,percent of total billed charges,70% of total billed charges,694.5,75,,,percent of total billed charges,75% of total billed charges,333.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,740.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,648.19,350,,,Fee Schedule,350% of CMS OPPS Rate,188.9,102,,,Fee Schedule,102% of CMS OPPS Rate,708.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,416.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,648.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,555.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,463,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,648.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,425.96,230,,,Fee Schedule,230% of CMS OPPS Rate,444.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,833.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,138.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.9,833.4,
T CELL ANTIGEN RECEPTOR BETA,4081340,CDM,310,RC,81340,HCPCS,Outpatient,,,1368,820.8,,739.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,208.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,208.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,957.6,70,,,percent of total billed charges,70% of total billed charges,1026,75,,,percent of total billed charges,75% of total billed charges,376.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1094.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,731.22,350,,,Fee Schedule,350% of CMS OPPS Rate,213.09,102,,,Fee Schedule,102% of CMS OPPS Rate,1046.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,235.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,615.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,957.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,820.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,232.13,100,,,Fee Schedule,100% of UHC Fee Schedule,957.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,480.51,230,,,Fee Schedule,230% of CMS OPPS Rate,656.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,100,,,Fee Schedule,100% of CMS OPPS Rate,208.92,1231.2,
T CELL ANTIGEN RECEPTOR GAMMA,4081342,CDM,310,RC,81342,HCPCS,Outpatient,,,1125,675,,713.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,201.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,787.5,70,,,percent of total billed charges,70% of total billed charges,843.75,75,,,percent of total billed charges,75% of total billed charges,362.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,900,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,705.25,350,,,Fee Schedule,350% of CMS OPPS Rate,205.53,102,,,Fee Schedule,102% of CMS OPPS Rate,860.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,506.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,787.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,675,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,223.88,100,,,Fee Schedule,100% of UHC Fee Schedule,787.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,463.45,230,,,Fee Schedule,230% of CMS OPPS Rate,540,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1012.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,201.5,100,,,Fee Schedule,100% of CMS OPPS Rate,176.29,1012.5,
UGT1A1 GENE ANALYSIS COMMON VARIANTS,4081350,CDM,300,RC,81350,HCPCS,Outpatient,,,828.72,497.23,,828.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,234,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,477.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,580.1,70,,,percent of total billed charges,70% of total billed charges,621.54,75,,,percent of total billed charges,75% of total billed charges,421.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,662.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819,350,,,Fee Schedule,350% of CMS OPPS Rate,238.68,102,,,Fee Schedule,102% of CMS OPPS Rate,633.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,372.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,580.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,497.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,234,100,,,Fee Schedule,100% of CMS OPPS Rate,210.6,100,,,Fee Schedule,100% of UHC Fee Schedule,580.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234,100,,,Fee Schedule,100% of CMS OPPS Rate,538.2,230,,,Fee Schedule,230% of CMS OPPS Rate,397.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,234,100,,,Fee Schedule,100% of CMS OPPS Rate,745.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,234,100,,,Fee Schedule,100% of CMS OPPS Rate,129.86,828.36,
HEMOGLOBIN SUBUNIT BETA,4081364,CDM,310,RC,81364,HCPCS,Outpatient,,,1622.9,973.74,,1149.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,324.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,661.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1136.03,70,,,percent of total billed charges,70% of total billed charges,1217.18,75,,,percent of total billed charges,75% of total billed charges,584.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1298.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1136.03,350,,,Fee Schedule,350% of CMS OPPS Rate,331.07,102,,,Fee Schedule,102% of CMS OPPS Rate,1241.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,279.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,730.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1136.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,973.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,292.12,100,,,Fee Schedule,100% of UHC Fee Schedule,1136.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,746.53,230,,,Fee Schedule,230% of CMS OPPS Rate,778.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1460.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,324.58,100,,,Fee Schedule,100% of CMS OPPS Rate,254.31,1460.61,
HLA CLASS 1 TYPING HLA A B OR C,4081373,CDM,300,RC,81373,HCPCS,Outpatient,,,472,283.2,,451.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,127.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,330.4,70,,,percent of total billed charges,70% of total billed charges,354,75,,,percent of total billed charges,75% of total billed charges,229.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,377.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446,350,,,Fee Schedule,350% of CMS OPPS Rate,129.97,102,,,Fee Schedule,102% of CMS OPPS Rate,361.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,212.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,330.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,123.73,100,,,Fee Schedule,100% of UHC Fee Schedule,330.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,293.08,230,,,Fee Schedule,230% of CMS OPPS Rate,226.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,424.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,127.43,100,,,Fee Schedule,100% of CMS OPPS Rate,73.96,451.1,
HLA CLASS 1 TYPING EG B27 EA,4081374,CDM,310,RC,81374,HCPCS,Outpatient,,,496,297.6,,263.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,347.2,70,,,percent of total billed charges,70% of total billed charges,372,75,,,percent of total billed charges,75% of total billed charges,133.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.15,350,,,Fee Schedule,350% of CMS OPPS Rate,75.81,102,,,Fee Schedule,102% of CMS OPPS Rate,379.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,223.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,297.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,80.83,100,,,Fee Schedule,100% of UHC Fee Schedule,347.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,170.95,230,,,Fee Schedule,230% of CMS OPPS Rate,238.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,446.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,100,,,Fee Schedule,100% of CMS OPPS Rate,74.33,446.4,
"HLA CLASS II TYPING, RESOLUT",4081376,CDM,300,RC,81376,HCPCS,Outpatient,,,452,271.2,,432.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,122.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,307.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,316.4,70,,,percent of total billed charges,70% of total billed charges,339,75,,,percent of total billed charges,75% of total billed charges,219.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,361.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,427.77,350,,,Fee Schedule,350% of CMS OPPS Rate,124.66,102,,,Fee Schedule,102% of CMS OPPS Rate,345.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,203.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,316.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,271.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,135.8,100,,,Fee Schedule,100% of UHC Fee Schedule,316.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,281.1,230,,,Fee Schedule,230% of CMS OPPS Rate,216.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,406.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,122.22,100,,,Fee Schedule,100% of CMS OPPS Rate,70.83,432.65,
HLA CLASS I TYPING HG RESOLUTION,4081381,CDM,300,RC,81381,HCPCS,Outpatient,,,1500,900,,601.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,169.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,346.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1050,70,,,percent of total billed charges,70% of total billed charges,1125,75,,,percent of total billed charges,75% of total billed charges,305.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,594.65,350,,,Fee Schedule,350% of CMS OPPS Rate,173.29,102,,,Fee Schedule,102% of CMS OPPS Rate,1147.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,258.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,675,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1050,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,152.91,100,,,Fee Schedule,100% of UHC Fee Schedule,1050,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,390.77,230,,,Fee Schedule,230% of CMS OPPS Rate,720,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1350,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,235.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,169.9,100,,,Fee Schedule,100% of CMS OPPS Rate,152.91,1350,
"HLA CLASS II TYPING, HIGH RESOLUT",4081382,CDM,310,RC,81382,HCPCS,Outpatient,,,842.4,505.44,,437.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,311.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,589.68,70,,,percent of total billed charges,70% of total billed charges,631.8,75,,,percent of total billed charges,75% of total billed charges,222.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,673.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,432.88,350,,,Fee Schedule,350% of CMS OPPS Rate,126.15,102,,,Fee Schedule,102% of CMS OPPS Rate,644.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,145.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,379.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,589.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,505.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,137.42,100,,,Fee Schedule,100% of UHC Fee Schedule,589.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,284.46,230,,,Fee Schedule,230% of CMS OPPS Rate,404.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,758.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.68,758.16,
HLA CLASS II TYPING H RESOLUTION,4081383,CDM,300,RC,81383,HCPCS,Outpatient,,,766,459.6,,386.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,109.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,274.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.2,70,,,percent of total billed charges,70% of total billed charges,574.5,75,,,percent of total billed charges,75% of total billed charges,196.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,612.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,381.95,350,,,Fee Schedule,350% of CMS OPPS Rate,111.31,102,,,Fee Schedule,102% of CMS OPPS Rate,585.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,344.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,459.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,121.26,100,,,Fee Schedule,100% of UHC Fee Schedule,536.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,250.99,230,,,Fee Schedule,230% of CMS OPPS Rate,367.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,689.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,100,,,Fee Schedule,100% of CMS OPPS Rate,109.13,689.4,
MOLECULAR PATH PROCEDURE LEV 1,4081400,CDM,300,RC,81400,HCPCS,Outpatient,,,700,420,,226.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,130.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,115.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.86,350,,,Fee Schedule,350% of CMS OPPS Rate,65.23,102,,,Fee Schedule,102% of CMS OPPS Rate,535.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,315,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,57.56,100,,,Fee Schedule,100% of UHC Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,147.1,230,,,Fee Schedule,230% of CMS OPPS Rate,336,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,630,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,57.56,630,
MOLECULAR PATH PROCEDURE LEV 2,4081401,CDM,300,RC,81401,HCPCS,Outpatient,,,833,499.8,,484.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,137,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,279.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,583.1,70,,,percent of total billed charges,70% of total billed charges,624.75,75,,,percent of total billed charges,75% of total billed charges,246.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,666.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,479.5,350,,,Fee Schedule,350% of CMS OPPS Rate,139.74,102,,,Fee Schedule,102% of CMS OPPS Rate,637.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,374.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,499.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,123.3,100,,,Fee Schedule,100% of UHC Fee Schedule,583.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,315.1,230,,,Fee Schedule,230% of CMS OPPS Rate,399.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,749.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,137,100,,,Fee Schedule,100% of CMS OPPS Rate,123.3,749.7,
MOLECULAR PATH PROCEDURE LEV 3,4081402,CDM,310,RC,81402,HCPCS,Outpatient,,,1291.68,775.01,,532.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,306.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,904.18,70,,,percent of total billed charges,70% of total billed charges,968.76,75,,,percent of total billed charges,75% of total billed charges,270.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1033.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,526.15,350,,,Fee Schedule,350% of CMS OPPS Rate,153.33,102,,,Fee Schedule,102% of CMS OPPS Rate,988.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,222.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,581.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,904.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,775.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,135.3,100,,,Fee Schedule,100% of UHC Fee Schedule,904.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,345.75,230,,,Fee Schedule,230% of CMS OPPS Rate,620.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1162.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,202.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,100,,,Fee Schedule,100% of CMS OPPS Rate,135.3,1162.51,
MOLECULAR PATHOLOGY LEV 4,4081403,CDM,310,RC,81403,HCPCS,Outpatient,,,440,264,,655.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,185.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,377.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,333.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,648.19,350,,,Fee Schedule,350% of CMS OPPS Rate,188.9,102,,,Fee Schedule,102% of CMS OPPS Rate,336.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,166.68,100,,,Fee Schedule,100% of UHC Fee Schedule,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,425.96,230,,,Fee Schedule,230% of CMS OPPS Rate,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,396,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,185.2,100,,,Fee Schedule,100% of CMS OPPS Rate,68.95,655.6,
MOLECULAR PATH PROCEDURE LEV 5,4081404,CDM,310,RC,81404,HCPCS,Outpatient,,,1202,721.2,,972.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,274.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,560.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,841.4,70,,,percent of total billed charges,70% of total billed charges,901.5,75,,,percent of total billed charges,75% of total billed charges,494.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,961.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,961.9,350,,,Fee Schedule,350% of CMS OPPS Rate,280.32,102,,,Fee Schedule,102% of CMS OPPS Rate,919.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,540.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,841.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,247.35,100,,,Fee Schedule,100% of UHC Fee Schedule,841.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,632.1,230,,,Fee Schedule,230% of CMS OPPS Rate,576.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,274.83,100,,,Fee Schedule,100% of CMS OPPS Rate,188.35,1081.8,
MOLECULAR PATH PROCEDURE LEVEL 6,4081405,CDM,310,RC,81405,HCPCS,Outpatient,,,753,451.8,,1066.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,301.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,614.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,527.1,70,,,percent of total billed charges,70% of total billed charges,564.75,75,,,percent of total billed charges,75% of total billed charges,542.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,602.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1054.72,350,,,Fee Schedule,350% of CMS OPPS Rate,307.37,102,,,Fee Schedule,102% of CMS OPPS Rate,576.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,338.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,527.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,451.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,271.22,100,,,Fee Schedule,100% of UHC Fee Schedule,527.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,693.1,230,,,Fee Schedule,230% of CMS OPPS Rate,361.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,677.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.35,100,,,Fee Schedule,100% of CMS OPPS Rate,118,1066.77,
MOLECULAR PATH PROCEDURE LEV 9,4081408,CDM,310,RC,81408,HCPCS,Outpatient,,,5000,3000,,7080,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2000,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2000,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4077.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3500,70,,,percent of total billed charges,70% of total billed charges,3750,75,,,percent of total billed charges,75% of total billed charges,3600,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7000,350,,,Fee Schedule,350% of CMS OPPS Rate,2040,102,,,Fee Schedule,102% of CMS OPPS Rate,3825,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,861.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2250,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3500,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3000,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,100,,,Fee Schedule,100% of UHC Fee Schedule,3500,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,4600,230,,,Fee Schedule,230% of CMS OPPS Rate,2400,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,4500,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,2000,100,,,Fee Schedule,100% of CMS OPPS Rate,783.5,7080,
GENETIC GLYCOGEN STORAGE PNL,4081443,CDM,310,RC,81443,HCPCS,Outpatient,,,5000,3000,,8667.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2448.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2448.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4992.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3500,70,,,percent of total billed charges,70% of total billed charges,3750,75,,,percent of total billed charges,75% of total billed charges,4407.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8569.96,350,,,Fee Schedule,350% of CMS OPPS Rate,2497.53,102,,,Fee Schedule,102% of CMS OPPS Rate,3825,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,861.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2250,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3500,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3000,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2203.7,100,,,Fee Schedule,100% of UHC Fee Schedule,3500,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5000,230,,,Fee Schedule,230% of CMS OPPS Rate,2400,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4500,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,783.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2448.56,100,,,Fee Schedule,100% of CMS OPPS Rate,783.5,8667.9,
TARGET GENOMIC S. ANAL. PANEL,4081445,CDM,310,RC,81445,HCPCS,Outpatient,,,3307,1984.2,,2116.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,597.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1219.08,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2314.9,70,,,percent of total billed charges,70% of total billed charges,2480.25,75,,,percent of total billed charges,75% of total billed charges,1076.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2645.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2092.68,350,,,Fee Schedule,350% of CMS OPPS Rate,609.86,102,,,Fee Schedule,102% of CMS OPPS Rate,2529.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,569.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1488.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2314.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1984.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,538.12,100,,,Fee Schedule,100% of UHC Fee Schedule,2314.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1375.19,230,,,Fee Schedule,230% of CMS OPPS Rate,1587.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,2976.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,597.91,100,,,Fee Schedule,100% of CMS OPPS Rate,518.21,2976.3,
TARGET GENOMIC S PANEL,4081450,CDM,310,RC,81450,HCPCS,Outpatient,,,2915,1749,,2688.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,759.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,759.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1548.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2040.5,70,,,percent of total billed charges,70% of total billed charges,2186.25,75,,,percent of total billed charges,75% of total billed charges,1367.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2658.35,350,,,Fee Schedule,350% of CMS OPPS Rate,774.72,102,,,Fee Schedule,102% of CMS OPPS Rate,2229.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,502.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2040.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1749,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,683.58,100,,,Fee Schedule,100% of UHC Fee Schedule,2040.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1746.91,230,,,Fee Schedule,230% of CMS OPPS Rate,1399.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2623.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,456.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,759.53,100,,,Fee Schedule,100% of CMS OPPS Rate,456.78,2688.73,
TARGETED GENOMIC SEQUENCE ANALYSIS,4081455,CDM,300,RC,81455,HCPCS,Outpatient,,,712.52,427.51,,10335.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2919.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2919.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5952.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,498.76,70,,,percent of total billed charges,70% of total billed charges,534.39,75,,,percent of total billed charges,75% of total billed charges,5255.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,570.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10218.6,350,,,Fee Schedule,350% of CMS OPPS Rate,2977.99,102,,,Fee Schedule,102% of CMS OPPS Rate,545.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,320.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,498.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,427.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2627.64,100,,,Fee Schedule,100% of UHC Fee Schedule,498.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,712.52,230,,,Fee Schedule,230% of CMS OPPS Rate,342.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,641.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2919.6,100,,,Fee Schedule,100% of CMS OPPS Rate,111.65,10335.38,
UNLISTED MOLECULAR PROCEDURE,4081479,CDM,300,RC,81479,HCPCS,Outpatient,,,402,241.2,,,,,,Other,Not Separately reimbursable,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,281.4,70,,,percent of total billed charges,70% of total billed charges,301.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.99,361.8,
OVARIAN MALIGNANCY ALGORITHM,4081500,CDM,310,RC,81500,HCPCS,Outpatient,,,1304,782.4,,922.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,260.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,531.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,912.8,70,,,percent of total billed charges,70% of total billed charges,978,75,,,percent of total billed charges,75% of total billed charges,468.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1043.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,911.75,350,,,Fee Schedule,350% of CMS OPPS Rate,265.71,102,,,Fee Schedule,102% of CMS OPPS Rate,997.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,224.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,912.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,782.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,234.45,100,,,Fee Schedule,100% of UHC Fee Schedule,912.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,599.15,230,,,Fee Schedule,230% of CMS OPPS Rate,625.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1173.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,260.5,100,,,Fee Schedule,100% of CMS OPPS Rate,204.34,1173.6,
FETAL CONGENITAL ABNORMALITIES,4081511,CDM,310,RC,81511,HCPCS,Outpatient,,,450,270,,543.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,153.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,312.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,276.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,537.25,350,,,Fee Schedule,350% of CMS OPPS Rate,156.57,102,,,Fee Schedule,102% of CMS OPPS Rate,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,138.15,100,,,Fee Schedule,100% of UHC Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,353.05,230,,,Fee Schedule,230% of CMS OPPS Rate,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,153.5,100,,,Fee Schedule,100% of CMS OPPS Rate,70.52,543.39,
ONCOLOGY BREAST MRNA GENE EXPRESSION,4081519,CDM,310,RC,81519,HCPCS,Outpatient,,,8548.55,5129.13,,13710.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3873,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3873,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7896.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5983.99,70,,,percent of total billed charges,70% of total billed charges,6411.41,75,,,percent of total billed charges,75% of total billed charges,6971.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6838.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13555.5,350,,,Fee Schedule,350% of CMS OPPS Rate,3950.46,102,,,Fee Schedule,102% of CMS OPPS Rate,6539.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1472.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3846.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5983.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5129.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3485.7,100,,,Fee Schedule,100% of UHC Fee Schedule,5983.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,8548.55,230,,,Fee Schedule,230% of CMS OPPS Rate,4103.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,7693.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1339.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,3873,100,,,Fee Schedule,100% of CMS OPPS Rate,1339.56,13710.42,
CHRONIC HEPATITIS C INFECTION,4081596,CDM,310,RC,81596,HCPCS,Outpatient,,,492,295.2,,255.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,55.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,72.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,147.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,344.4,70,,,percent of total billed charges,70% of total billed charges,369,75,,,percent of total billed charges,75% of total billed charges,129.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.66,350,,,Fee Schedule,350% of CMS OPPS Rate,73.63,102,,,Fee Schedule,102% of CMS OPPS Rate,376.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,221.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,344.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,64.97,100,,,Fee Schedule,100% of UHC Fee Schedule,344.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,166.03,230,,,Fee Schedule,230% of CMS OPPS Rate,236.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,442.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of CMS OPPS Rate,55.87,442.8,
EBV PNL (AB EARLY AG),4081651,CDM,302,RC,86663,HCPCS,Outpatient,,,158.4,95.04,,46.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges,118.8,75,,,percent of total billed charges,75% of total billed charges,23.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.92,350,,,Fee Schedule,350% of CMS OPPS Rate,13.38,102,,,Fee Schedule,102% of CMS OPPS Rate,121.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.58,100,,,Fee Schedule,100% of UHC Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,230,,,Fee Schedule,230% of CMS OPPS Rate,76.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,142.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,142.56,
EBV ANTIGEN,4081653,CDM,302,RC,86664,HCPCS,Outpatient,,,158.4,95.04,,54.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges,118.8,75,,,percent of total billed charges,75% of total billed charges,27.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.51,350,,,Fee Schedule,350% of CMS OPPS Rate,15.59,102,,,Fee Schedule,102% of CMS OPPS Rate,121.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,35.16,230,,,Fee Schedule,230% of CMS OPPS Rate,76.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,142.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,142.56,
Blood test to diagnose mononucleosis,4081654,CDM,302,RC,86665,HCPCS,Outpatient,,,158.4,95.04,,64.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges,118.8,75,,,percent of total billed charges,75% of total billed charges,32.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.49,350,,,Fee Schedule,350% of CMS OPPS Rate,18.5,102,,,Fee Schedule,102% of CMS OPPS Rate,121.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of UHC Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,41.72,230,,,Fee Schedule,230% of CMS OPPS Rate,76.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,142.56,
ACYLCARNITINE QUANTITIVE,4082017,CDM,301,RC,82017,HCPCS,Outpatient,,,126,75.6,,59.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,30.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.04,350,,,Fee Schedule,350% of CMS OPPS Rate,17.2,102,,,Fee Schedule,102% of CMS OPPS Rate,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of UHC Fee Schedule,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,38.8,230,,,Fee Schedule,230% of CMS OPPS Rate,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,113.4,
ACTH(ADRENOCORTICOTR HOR),4082024,CDM,301,RC,82024,HCPCS,Outpatient,,,361.35,216.81,,136.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,38.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,252.95,70,,,percent of total billed charges,70% of total billed charges,271.01,75,,,percent of total billed charges,75% of total billed charges,69.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,289.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,135.17,350,,,Fee Schedule,350% of CMS OPPS Rate,39.39,102,,,Fee Schedule,102% of CMS OPPS Rate,276.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,162.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,42.91,100,,,Fee Schedule,100% of UHC Fee Schedule,252.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,88.82,230,,,Fee Schedule,230% of CMS OPPS Rate,173.45,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,325.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,100,,,Fee Schedule,100% of CMS OPPS Rate,38.61,325.22,
ALDOLASE,4082085,CDM,301,RC,82085,HCPCS,Outpatient,,,168.85,101.31,,34.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.71,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.2,70,,,percent of total billed charges,70% of total billed charges,126.64,75,,,percent of total billed charges,75% of total billed charges,17.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.98,350,,,Fee Schedule,350% of CMS OPPS Rate,9.9,102,,,Fee Schedule,102% of CMS OPPS Rate,129.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,75.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,10.79,100,,,Fee Schedule,100% of UHC Fee Schedule,118.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,22.33,230,,,Fee Schedule,230% of CMS OPPS Rate,81.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,151.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9.71,151.97,
ALDOSTERONE,4082088,CDM,301,RC,82088,HCPCS,Outpatient,,,504.9,302.94,,144.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,102.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges,378.68,75,,,percent of total billed charges,75% of total billed charges,73.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,403.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.62,350,,,Fee Schedule,350% of CMS OPPS Rate,41.56,102,,,Fee Schedule,102% of CMS OPPS Rate,386.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,227.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,45.28,100,,,Fee Schedule,100% of UHC Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,93.72,230,,,Fee Schedule,230% of CMS OPPS Rate,242.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,454.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,454.41,
ALPHA FETOPROTEIN TUMOR M,4082090,CDM,301,RC,82105,HCPCS,Outpatient,,,105.05,63.03,,59.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.54,70,,,percent of total billed charges,70% of total billed charges,78.79,75,,,percent of total billed charges,75% of total billed charges,30.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.69,350,,,Fee Schedule,350% of CMS OPPS Rate,17.1,102,,,Fee Schedule,102% of CMS OPPS Rate,80.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,47.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of UHC Fee Schedule,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,230,,,Fee Schedule,230% of CMS OPPS Rate,50.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.69,94.55,
ALPHA 1 ANTITRYPSIN PHENOTYPR,4082104,CDM,301,RC,82104,HCPCS,Outpatient,,,210,126,,51.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,26.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.61,350,,,Fee Schedule,350% of CMS OPPS Rate,14.74,102,,,Fee Schedule,102% of CMS OPPS Rate,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of UHC Fee Schedule,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.25,230,,,Fee Schedule,230% of CMS OPPS Rate,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,189,
AFP L3 FRACTION ISOFORM AND TOTAL,4082107,CDM,301,RC,82107,HCPCS,Outpatient,,,439.4,263.64,,228.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,64.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,162.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,307.58,70,,,percent of total billed charges,70% of total billed charges,329.55,75,,,percent of total billed charges,75% of total billed charges,115.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,351.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.43,350,,,Fee Schedule,350% of CMS OPPS Rate,65.69,102,,,Fee Schedule,102% of CMS OPPS Rate,336.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,197.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,307.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,263.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,71.57,100,,,Fee Schedule,100% of UHC Fee Schedule,307.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,148.14,230,,,Fee Schedule,230% of CMS OPPS Rate,210.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,395.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,395.46,
ALUMINUM,4082108,CDM,301,RC,82108,HCPCS,Outpatient,,,276,165.6,,90.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.2,70,,,percent of total billed charges,70% of total billed charges,207,75,,,percent of total billed charges,75% of total billed charges,45.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.18,350,,,Fee Schedule,350% of CMS OPPS Rate,25.98,102,,,Fee Schedule,102% of CMS OPPS Rate,211.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,124.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,28.31,100,,,Fee Schedule,100% of UHC Fee Schedule,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,58.6,230,,,Fee Schedule,230% of CMS OPPS Rate,132.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,248.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,25.48,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,248.4,
"AMINO ACID,QUANT PEDIATIC",4082129,CDM,301,RC,82139,HCPCS,Outpatient,,,867.5,520.5,,59.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,607.25,70,,,percent of total billed charges,70% of total billed charges,650.63,75,,,percent of total billed charges,75% of total billed charges,30.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,694,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.04,350,,,Fee Schedule,350% of CMS OPPS Rate,17.2,102,,,Fee Schedule,102% of CMS OPPS Rate,663.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,390.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,607.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of UHC Fee Schedule,607.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,38.8,230,,,Fee Schedule,230% of CMS OPPS Rate,416.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,780.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,100,,,Fee Schedule,100% of CMS OPPS Rate,16.87,780.75,
AMITRIPTYLINE CONFIRM,4082132,CDM,300,RC,G0480,HCPCS,Outpatient,,,81,48.6,,405.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,88.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,205.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.5,350,,,Fee Schedule,350% of CMS OPPS Rate,116.71,102,,,Fee Schedule,102% of CMS OPPS Rate,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,102.99,100,,,Fee Schedule,100% of UHC Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,81,230,,,Fee Schedule,230% of CMS OPPS Rate,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,36.45,405.08,
ALA-AMINOLEVULINIC AC,4082135,CDM,301,RC,82135,HCPCS,Outpatient,,,154.8,92.88,,58.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,108.36,70,,,percent of total billed charges,70% of total billed charges,116.1,75,,,percent of total billed charges,75% of total billed charges,29.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,123.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.57,350,,,Fee Schedule,350% of CMS OPPS Rate,16.77,102,,,Fee Schedule,102% of CMS OPPS Rate,118.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,69.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of UHC Fee Schedule,108.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,37.83,230,,,Fee Schedule,230% of CMS OPPS Rate,74.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,139.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,139.32,
AMINO ACIDS 2 TO 5 QUANTITATIVE EA,4082136,CDM,301,RC,82136,HCPCS,Outpatient,,,253,151.8,,69.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,35.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.63,350,,,Fee Schedule,350% of CMS OPPS Rate,20,102,,,Fee Schedule,102% of CMS OPPS Rate,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,100,,,Fee Schedule,100% of UHC Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,45.1,230,,,Fee Schedule,230% of CMS OPPS Rate,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,19.61,100,,,Fee Schedule,100% of CMS OPPS Rate,18.75,227.7,
AMNIOTIC FLUID SCAN,4082143,CDM,301,RC,82143,HCPCS,Outpatient,,,89,53.4,,33.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,16.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.72,350,,,Fee Schedule,350% of CMS OPPS Rate,9.53,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,8.42,100,,,Fee Schedule,100% of UHC Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.5,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,100,,,Fee Schedule,100% of CMS OPPS Rate,8.42,80.1,
AMPHETAMINE CONFIRM 1 OR 2,4082145,CDM,301,RC,80324,HCPCS,Outpatient,,,57.6,34.56,,,,,,Other,Not Separately reimbursable,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges,43.2,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.03,51.84,
ANDROSTANEDIOL GLUCURONIDE,4082154,CDM,300,RC,82154,HCPCS,Outpatient,,,346,207.6,,102.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,242.2,70,,,percent of total billed charges,70% of total billed charges,259.5,75,,,percent of total billed charges,75% of total billed charges,51.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,276.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,100.9,350,,,Fee Schedule,350% of CMS OPPS Rate,29.4,102,,,Fee Schedule,102% of CMS OPPS Rate,264.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,155.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,242.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,32.04,100,,,Fee Schedule,100% of UHC Fee Schedule,242.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,66.3,230,,,Fee Schedule,230% of CMS OPPS Rate,166.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,311.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,100,,,Fee Schedule,100% of CMS OPPS Rate,28.83,311.4,
ANGIOTENSIN CONVERT ENZ,4082164,CDM,301,RC,82164,HCPCS,Outpatient,,,197.45,118.47,,51.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.22,70,,,percent of total billed charges,70% of total billed charges,148.09,75,,,percent of total billed charges,75% of total billed charges,26.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,157.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.1,350,,,Fee Schedule,350% of CMS OPPS Rate,14.89,102,,,Fee Schedule,102% of CMS OPPS Rate,151.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,88.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.23,100,,,Fee Schedule,100% of UHC Fee Schedule,138.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,33.58,230,,,Fee Schedule,230% of CMS OPPS Rate,94.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,177.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.6,177.71,
ANTI-BLASTOMYCES AB,4082168,CDM,302,RC,86612,HCPCS,Outpatient,,,131.4,78.84,,45.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,91.98,70,,,percent of total billed charges,70% of total billed charges,98.55,75,,,percent of total billed charges,75% of total billed charges,23.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,105.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.15,350,,,Fee Schedule,350% of CMS OPPS Rate,13.15,102,,,Fee Schedule,102% of CMS OPPS Rate,100.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,59.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of UHC Fee Schedule,91.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,29.67,230,,,Fee Schedule,230% of CMS OPPS Rate,63.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,118.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,118.26,
Blood test to determine cause of inappropriate blood clot formation,4082169,CDM,302,RC,86147,HCPCS,Outpatient,,,139.7,83.82,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges,104.78,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,106.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,62.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,67.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,125.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,125.73,
LIPOPROTEIN,4082172,CDM,301,RC,82172,HCPCS,Outpatient,,,68.2,40.92,,74.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges,51.15,75,,,percent of total billed charges,75% of total billed charges,37.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.81,350,,,Fee Schedule,350% of CMS OPPS Rate,21.51,102,,,Fee Schedule,102% of CMS OPPS Rate,52.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,30.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,18.98,100,,,Fee Schedule,100% of UHC Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,48.5,230,,,Fee Schedule,230% of CMS OPPS Rate,32.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.09,100,,,Fee Schedule,100% of CMS OPPS Rate,10.69,74.65,
ASCORBIC ACID BLOOD,4082180,CDM,301,RC,82180,HCPCS,Outpatient,,,248,148.8,,35.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.89,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,173.6,70,,,percent of total billed charges,70% of total billed charges,186,75,,,percent of total billed charges,75% of total billed charges,17.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.61,350,,,Fee Schedule,350% of CMS OPPS Rate,10.08,102,,,Fee Schedule,102% of CMS OPPS Rate,189.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,111.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,10.98,100,,,Fee Schedule,100% of UHC Fee Schedule,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,22.74,230,,,Fee Schedule,230% of CMS OPPS Rate,119.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,223.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,223.2,
ANTI-MUMPS AB,4082190,CDM,302,RC,86735,HCPCS,Outpatient,,,50.6,30.36,,46.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,23.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.67,350,,,Fee Schedule,350% of CMS OPPS Rate,13.31,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,30.01,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,46.19,
B2 MICROGLOBULIN,4082200,CDM,301,RC,82232,HCPCS,Outpatient,,,130.5,78.3,,57.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,91.35,70,,,percent of total billed charges,70% of total billed charges,97.88,75,,,percent of total billed charges,75% of total billed charges,29.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.63,350,,,Fee Schedule,350% of CMS OPPS Rate,16.5,102,,,Fee Schedule,102% of CMS OPPS Rate,99.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,58.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,17.97,100,,,Fee Schedule,100% of UHC Fee Schedule,91.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,37.21,230,,,Fee Schedule,230% of CMS OPPS Rate,62.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,100,,,Fee Schedule,100% of CMS OPPS Rate,16.18,117.45,
BARBITURATES CONFIRM,4082205,CDM,301,RC,80345,HCPCS,Outpatient,,,147,88.2,,,,,,Other,Not Separately reimbursable,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,132.3,
OCCULT BLD FHG QUAL 1 3,4082274,CDM,300,RC,82274,HCPCS,Outpatient,,,81,48.6,,56.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,28.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.72,350,,,Fee Schedule,350% of CMS OPPS Rate,16.23,102,,,Fee Schedule,102% of CMS OPPS Rate,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,100,,,Fee Schedule,100% of UHC Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,36.61,230,,,Fee Schedule,230% of CMS OPPS Rate,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,72.9,
CADMIUM,4082300,CDM,301,RC,82300,HCPCS,Outpatient,,,95,57,,83.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,58.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.5,70,,,percent of total billed charges,70% of total billed charges,71.25,75,,,percent of total billed charges,75% of total billed charges,42.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.74,350,,,Fee Schedule,350% of CMS OPPS Rate,24.11,102,,,Fee Schedule,102% of CMS OPPS Rate,72.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,42.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,25.72,100,,,Fee Schedule,100% of UHC Fee Schedule,66.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,54.37,230,,,Fee Schedule,230% of CMS OPPS Rate,45.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,85.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,100,,,Fee Schedule,100% of CMS OPPS Rate,23.64,85.5,
"CALCITONIN, SERUM",4082308,CDM,300,RC,82308,HCPCS,Outpatient,,,73.7,44.22,,94.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.79,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.59,70,,,percent of total billed charges,70% of total billed charges,55.28,75,,,percent of total billed charges,75% of total billed charges,48.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.76,350,,,Fee Schedule,350% of CMS OPPS Rate,27.32,102,,,Fee Schedule,102% of CMS OPPS Rate,56.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,33.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,100,,,Fee Schedule,100% of UHC Fee Schedule,51.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,61.61,230,,,Fee Schedule,230% of CMS OPPS Rate,35.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,66.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,100,,,Fee Schedule,100% of CMS OPPS Rate,26.79,94.83,
CALCULIUS ANALYSIS QUANT,4082360,CDM,301,RC,82360,HCPCS,Outpatient,,,116.18,69.71,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.33,70,,,percent of total billed charges,70% of total billed charges,87.14,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,88.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,52.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,81.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,55.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,104.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,104.56,
CALCULUS SPECTROSCOPY,4082365,CDM,301,RC,82365,HCPCS,Outpatient,,,159.5,95.7,,45.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,111.65,70,,,percent of total billed charges,70% of total billed charges,119.63,75,,,percent of total billed charges,75% of total billed charges,23.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,127.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.15,350,,,Fee Schedule,350% of CMS OPPS Rate,13.15,102,,,Fee Schedule,102% of CMS OPPS Rate,122.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,71.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,14.33,100,,,Fee Schedule,100% of UHC Fee Schedule,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,29.67,230,,,Fee Schedule,230% of CMS OPPS Rate,76.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,143.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,143.55,
CARBOHYDRATE DEFICIENT TRANSFER,4082373,CDM,301,RC,82373,HCPCS,Outpatient,,,89,53.4,,63.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.89,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,32.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.21,350,,,Fee Schedule,350% of CMS OPPS Rate,18.42,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.06,100,,,Fee Schedule,100% of UHC Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,41.53,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,10.89,80.1,
CAROTENE,4082380,CDM,301,RC,82380,HCPCS,Outpatient,,,97,58.2,,32.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,67.9,70,,,percent of total billed charges,70% of total billed charges,72.75,75,,,percent of total billed charges,75% of total billed charges,16.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.27,350,,,Fee Schedule,350% of CMS OPPS Rate,9.4,102,,,Fee Schedule,102% of CMS OPPS Rate,74.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,10.25,100,,,Fee Schedule,100% of UHC Fee Schedule,67.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,21.2,230,,,Fee Schedule,230% of CMS OPPS Rate,46.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,87.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9.22,87.3,
CATECHOLAMINES-URINE-FRACTIONATED,4082382,CDM,301,RC,82384,HCPCS,Outpatient,,,182.6,109.56,,89.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.82,70,,,percent of total billed charges,70% of total billed charges,136.95,75,,,percent of total billed charges,75% of total billed charges,45.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,146.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.37,350,,,Fee Schedule,350% of CMS OPPS Rate,25.75,102,,,Fee Schedule,102% of CMS OPPS Rate,139.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,82.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,100,,,Fee Schedule,100% of UHC Fee Schedule,127.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,58.07,230,,,Fee Schedule,230% of CMS OPPS Rate,87.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,164.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.25,164.34,
CERULOPLASMIN,4082390,CDM,301,RC,82390,HCPCS,Outpatient,,,131.45,78.87,,38.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,92.02,70,,,percent of total billed charges,70% of total billed charges,98.59,75,,,percent of total billed charges,75% of total billed charges,19.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,105.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.59,350,,,Fee Schedule,350% of CMS OPPS Rate,10.95,102,,,Fee Schedule,102% of CMS OPPS Rate,100.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,59.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of UHC Fee Schedule,92.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.7,230,,,Fee Schedule,230% of CMS OPPS Rate,63.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,118.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,118.31,
CHEMILUMINESCENT ASSAY,4082397,CDM,301,RC,82397,HCPCS,Outpatient,,,85.95,51.57,,49.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.54,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.17,70,,,percent of total billed charges,70% of total billed charges,64.46,75,,,percent of total billed charges,75% of total billed charges,25.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.42,350,,,Fee Schedule,350% of CMS OPPS Rate,14.4,102,,,Fee Schedule,102% of CMS OPPS Rate,65.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.69,100,,,Fee Schedule,100% of UHC Fee Schedule,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,32.47,230,,,Fee Schedule,230% of CMS OPPS Rate,41.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,77.36,
"CHROMIUM, BLOOD",4082495,CDM,300,RC,82495,HCPCS,Outpatient,,,76.45,45.87,,71.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.52,70,,,percent of total billed charges,70% of total billed charges,57.34,75,,,percent of total billed charges,75% of total billed charges,36.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.98,350,,,Fee Schedule,350% of CMS OPPS Rate,20.68,102,,,Fee Schedule,102% of CMS OPPS Rate,58.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,34.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,22.54,100,,,Fee Schedule,100% of UHC Fee Schedule,53.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,46.64,230,,,Fee Schedule,230% of CMS OPPS Rate,36.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.28,71.79,
CITRATE-UR-24 HR,4082507,CDM,301,RC,82507,HCPCS,Outpatient,,,301.4,180.84,,98.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,210.98,70,,,percent of total billed charges,70% of total billed charges,226.05,75,,,percent of total billed charges,75% of total billed charges,50.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.3,350,,,Fee Schedule,350% of CMS OPPS Rate,28.35,102,,,Fee Schedule,102% of CMS OPPS Rate,230.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,135.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,100,,,Fee Schedule,100% of UHC Fee Schedule,210.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,63.94,230,,,Fee Schedule,230% of CMS OPPS Rate,144.67,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,271.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,271.26,
COCAINE CONFIRM,4082520,CDM,301,RC,80353,HCPCS,Outpatient,,,150,90,,,,,,Other,Not Separately reimbursable,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,135,
COLLAGEN CROSS LINKS,4082523,CDM,301,RC,82523,HCPCS,Outpatient,,,62.15,37.29,,66.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.51,70,,,percent of total billed charges,70% of total billed charges,46.61,75,,,percent of total billed charges,75% of total billed charges,33.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.38,350,,,Fee Schedule,350% of CMS OPPS Rate,19.05,102,,,Fee Schedule,102% of CMS OPPS Rate,47.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,27.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,20.76,100,,,Fee Schedule,100% of UHC Fee Schedule,43.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,42.96,230,,,Fee Schedule,230% of CMS OPPS Rate,29.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,55.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,66.12,
"COPPER, RBC",4082525,CDM,301,RC,82525,HCPCS,Outpatient,,,70.4,42.24,,43.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49.28,70,,,percent of total billed charges,70% of total billed charges,52.8,75,,,percent of total billed charges,75% of total billed charges,22.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.43,350,,,Fee Schedule,350% of CMS OPPS Rate,12.65,102,,,Fee Schedule,102% of CMS OPPS Rate,53.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of UHC Fee Schedule,49.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,28.54,230,,,Fee Schedule,230% of CMS OPPS Rate,33.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,63.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,100,,,Fee Schedule,100% of CMS OPPS Rate,12.41,63.36,
CREATINE,4082540,CDM,301,RC,82540,HCPCS,Outpatient,,,150,90,,16.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,8.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.24,350,,,Fee Schedule,350% of CMS OPPS Rate,4.73,102,,,Fee Schedule,102% of CMS OPPS Rate,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,5.15,100,,,Fee Schedule,100% of UHC Fee Schedule,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,230,,,Fee Schedule,230% of CMS OPPS Rate,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,100,,,Fee Schedule,100% of CMS OPPS Rate,4.63,135,
COLUMN CHROMATOGRAPHY QUAL/QUAN,4082542,CDM,300,RC,82542,HCPCS,Outpatient,,,124.65,74.79,,85.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,43.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.31,350,,,Fee Schedule,350% of CMS OPPS Rate,24.57,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.68,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,55.4,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,24.09,100,,,Fee Schedule,100% of CMS OPPS Rate,21.68,112.19,
"CK ISOENZ(ELECTROPH), SER",4082552,CDM,301,RC,82552,HCPCS,Outpatient,,,83.05,49.83,,47.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.14,70,,,percent of total billed charges,70% of total billed charges,62.29,75,,,percent of total billed charges,75% of total billed charges,24.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.86,350,,,Fee Schedule,350% of CMS OPPS Rate,13.65,102,,,Fee Schedule,102% of CMS OPPS Rate,63.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,37.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,58.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,30.79,230,,,Fee Schedule,230% of CMS OPPS Rate,39.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,74.75,
CRYTOCOCCUS AG AGGLU,4082572,CDM,302,RC,86641,HCPCS,Outpatient,,,72.5,43.5,,51.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,50.75,70,,,percent of total billed charges,70% of total billed charges,54.38,75,,,percent of total billed charges,75% of total billed charges,25.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.43,350,,,Fee Schedule,350% of CMS OPPS Rate,14.69,102,,,Fee Schedule,102% of CMS OPPS Rate,55.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,32.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16.01,100,,,Fee Schedule,100% of UHC Fee Schedule,50.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,33.14,230,,,Fee Schedule,230% of CMS OPPS Rate,34.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,65.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,65.25,
"CRYOGLOBULIN, SERUM",4082595,CDM,301,RC,82595,HCPCS,Outpatient,,,65,39,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.18,100,,,Fee Schedule,100% of UHC Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,58.5,
CYSTATIN C,4082610,CDM,301,RC,82610,HCPCS,Outpatient,,,165,99,,65.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,33.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.82,350,,,Fee Schedule,350% of CMS OPPS Rate,18.89,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,42.59,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,18.52,100,,,Fee Schedule,100% of CMS OPPS Rate,6.46,148.5,
DIHYDROTESTOSTERONE,4082642,CDM,301,RC,82642,HCPCS,Outpatient,,,148,88.8,,103.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,103.6,70,,,percent of total billed charges,70% of total billed charges,111,75,,,percent of total billed charges,75% of total billed charges,52.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.48,350,,,Fee Schedule,350% of CMS OPPS Rate,29.86,102,,,Fee Schedule,102% of CMS OPPS Rate,113.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,66.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,103.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of UHC Fee Schedule,103.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,67.34,230,,,Fee Schedule,230% of CMS OPPS Rate,71.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,133.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,25.18,133.2,
ANABOLIC STEROIDS CONFIRM 1 OR 2,4082651,CDM,301,RC,80327,HCPCS,Outpatient,,,117.7,70.62,,,,,,Other,Not Separately reimbursable,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,82.39,70,,,percent of total billed charges,70% of total billed charges,88.28,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,94.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.44,105.93,
"ELASTASE, PANCREATIC FECAL QN",4082653,CDM,300,RC,82653,HCPCS,Outpatient,,,418,250.8,,81.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209,50,,,percent of total billed charges,pays at 50% of total billed charges,292.6,70,,,percent of total billed charges,70% of total billed charges,313.5,75,,,percent of total billed charges,75% of total billed charges,41.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,334.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.39,350,,,Fee Schedule,350% of CMS OPPS Rate,23.42,102,,,Fee Schedule,102% of CMS OPPS Rate,319.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,188.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,250.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,209,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,292.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,52.83,230,,,Fee Schedule,230% of CMS OPPS Rate,200.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,376.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of CMS OPPS Rate,17.23,376.2,
"PANCREATIC ELASTASE, FECA",4082656,CDM,301,RC,82656,HCPCS,Outpatient,,,225,135,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,157.5,70,,,percent of total billed charges,70% of total billed charges,168.75,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,180,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,172.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,101.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,157.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,108,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,202.5,
ENZYME ACTIVITY IN BLOOD,4082657,CDM,300,RC,82657,HCPCS,Outpatient,,,276.75,166.05,,78.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.73,70,,,percent of total billed charges,70% of total billed charges,207.56,75,,,percent of total billed charges,75% of total billed charges,39.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,221.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,77.59,350,,,Fee Schedule,350% of CMS OPPS Rate,22.61,102,,,Fee Schedule,102% of CMS OPPS Rate,211.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,124.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,20.06,100,,,Fee Schedule,100% of UHC Fee Schedule,193.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,230,,,Fee Schedule,230% of CMS OPPS Rate,132.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,249.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.17,100,,,Fee Schedule,100% of CMS OPPS Rate,20.06,249.08,
ERYTHOPOIETIN,4082671,CDM,301,RC,82668,HCPCS,Outpatient,,,99.55,59.73,,66.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.79,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.69,70,,,percent of total billed charges,70% of total billed charges,74.66,75,,,percent of total billed charges,75% of total billed charges,33.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.76,350,,,Fee Schedule,350% of CMS OPPS Rate,19.16,102,,,Fee Schedule,102% of CMS OPPS Rate,76.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of UHC Fee Schedule,69.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,43.21,230,,,Fee Schedule,230% of CMS OPPS Rate,47.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,89.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,89.6,
"ESTROGEN, TOTAL",4082672,CDM,301,RC,82672,HCPCS,Outpatient,,,257.4,154.44,,76.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.18,70,,,percent of total billed charges,70% of total billed charges,193.05,75,,,percent of total billed charges,75% of total billed charges,39.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,205.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.95,350,,,Fee Schedule,350% of CMS OPPS Rate,22.13,102,,,Fee Schedule,102% of CMS OPPS Rate,196.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,115.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,24.1,100,,,Fee Schedule,100% of UHC Fee Schedule,180.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,49.91,230,,,Fee Schedule,230% of CMS OPPS Rate,123.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,231.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,231.66,
ESTRONE,4082679,CDM,301,RC,82679,HCPCS,Outpatient,,,81.45,48.87,,88.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.02,70,,,percent of total billed charges,70% of total billed charges,61.09,75,,,percent of total billed charges,75% of total billed charges,44.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.32,350,,,Fee Schedule,350% of CMS OPPS Rate,25.44,102,,,Fee Schedule,102% of CMS OPPS Rate,62.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,27.73,100,,,Fee Schedule,100% of UHC Fee Schedule,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,57.38,230,,,Fee Schedule,230% of CMS OPPS Rate,39.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,88.32,
Blood test to measure a type of estrogen in the blood,4082680,CDM,301,RC,82670,HCPCS,Outpatient,,,166.1,99.66,,98.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,116.27,70,,,percent of total billed charges,70% of total billed charges,124.58,75,,,percent of total billed charges,75% of total billed charges,50.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.79,350,,,Fee Schedule,350% of CMS OPPS Rate,28.49,102,,,Fee Schedule,102% of CMS OPPS Rate,127.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.04,100,,,Fee Schedule,100% of UHC Fee Schedule,116.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,64.26,230,,,Fee Schedule,230% of CMS OPPS Rate,79.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,149.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,149.49,
Blood test to measure a type of estrogen in the blood,4082680,CDM,301,RC,82670,HCPCS,Outpatient,,,,,,98.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,97.79,350,,,Fee Schedule,350% of CMS OPPS Rate,28.49,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.04,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,98.9,
ETHOSUXIMIDE,4082692,CDM,301,RC,80168,HCPCS,Outpatient,,,164,98.4,,57.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,29.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.19,350,,,Fee Schedule,350% of CMS OPPS Rate,16.66,102,,,Fee Schedule,102% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,18.15,100,,,Fee Schedule,100% of UHC Fee Schedule,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,37.58,230,,,Fee Schedule,230% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,147.6,
THYROID STIM.IMMUNOGLOB,4082700,CDM,301,RC,84445,HCPCS,Outpatient,,,615.45,369.27,,180.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.43,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,50.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,430.82,70,,,percent of total billed charges,70% of total billed charges,461.59,75,,,percent of total billed charges,75% of total billed charges,91.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,492.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.01,350,,,Fee Schedule,350% of CMS OPPS Rate,51.87,102,,,Fee Schedule,102% of CMS OPPS Rate,470.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,276.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,430.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,369.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,56.5,100,,,Fee Schedule,100% of UHC Fee Schedule,430.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,116.97,230,,,Fee Schedule,230% of CMS OPPS Rate,295.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,553.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,22.43,553.91,
FAT-STOOL-QUANT 72 HR,4082710,CDM,301,RC,82710,HCPCS,Outpatient,,,232,139.2,,59.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,162.4,70,,,percent of total billed charges,70% of total billed charges,174,75,,,percent of total billed charges,75% of total billed charges,30.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,185.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,350,,,Fee Schedule,350% of CMS OPPS Rate,17.13,102,,,Fee Schedule,102% of CMS OPPS Rate,177.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,104.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of UHC Fee Schedule,162.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,230,,,Fee Schedule,230% of CMS OPPS Rate,111.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,208.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,208.8,
GALACTOSE 1 PHOSPHATE QUANT,4082775,CDM,301,RC,82775,HCPCS,Outpatient,,,393.4,236.04,,74.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,275.38,70,,,percent of total billed charges,70% of total billed charges,295.05,75,,,percent of total billed charges,75% of total billed charges,37.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,314.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.74,350,,,Fee Schedule,350% of CMS OPPS Rate,21.49,102,,,Fee Schedule,102% of CMS OPPS Rate,300.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,177.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,275.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,236.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.41,100,,,Fee Schedule,100% of UHC Fee Schedule,275.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,48.46,230,,,Fee Schedule,230% of CMS OPPS Rate,188.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,354.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.07,354.06,
Test to determine levels of immunoglobulins in the blood,4082782,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
IGE-IMMUNOGLOBULIN E,4082785,CDM,301,RC,82785,HCPCS,Outpatient,,,57.75,34.65,,58.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges,43.31,75,,,percent of total billed charges,75% of total billed charges,29.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.61,350,,,Fee Schedule,350% of CMS OPPS Rate,16.78,102,,,Fee Schedule,102% of CMS OPPS Rate,44.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,18.29,100,,,Fee Schedule,100% of UHC Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,37.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,58.26,
GLUCAGON,4082943,CDM,301,RC,82943,HCPCS,Outpatient,,,242,145.2,,50.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,169.4,70,,,percent of total billed charges,70% of total billed charges,181.5,75,,,percent of total billed charges,75% of total billed charges,25.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,193.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.01,350,,,Fee Schedule,350% of CMS OPPS Rate,14.57,102,,,Fee Schedule,102% of CMS OPPS Rate,185.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,108.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.88,100,,,Fee Schedule,100% of UHC Fee Schedule,169.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,32.86,230,,,Fee Schedule,230% of CMS OPPS Rate,116.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,217.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,100,,,Fee Schedule,100% of CMS OPPS Rate,14.29,217.8,
G6PD (QUANTITATIVE),4082955,CDM,301,RC,82955,HCPCS,Outpatient,,,115.5,69.3,,34.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,17.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,350,,,Fee Schedule,350% of CMS OPPS Rate,9.89,102,,,Fee Schedule,102% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,10.77,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.31,230,,,Fee Schedule,230% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9.69,103.95,
GLUTATHIONE,4082978,CDM,301,RC,82978,HCPCS,Outpatient,,,97.26,58.36,,54.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.08,70,,,percent of total billed charges,70% of total billed charges,72.95,75,,,percent of total billed charges,75% of total billed charges,27.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.07,350,,,Fee Schedule,350% of CMS OPPS Rate,15.75,102,,,Fee Schedule,102% of CMS OPPS Rate,74.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of UHC Fee Schedule,68.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,35.53,230,,,Fee Schedule,230% of CMS OPPS Rate,46.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,87.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.45,87.53,
"HAPTOGLOBIN,SERUM",4083010,CDM,301,RC,83010,HCPCS,Outpatient,,,103.95,62.37,,44.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges,77.96,75,,,percent of total billed charges,75% of total billed charges,22.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.03,350,,,Fee Schedule,350% of CMS OPPS Rate,12.83,102,,,Fee Schedule,102% of CMS OPPS Rate,79.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of UHC Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.93,230,,,Fee Schedule,230% of CMS OPPS Rate,49.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,93.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,93.56,
"HEMOGLOBIN ELECTROPH, BLD",4083020,CDM,301,RC,83020,HCPCS,Outpatient,,,192.6,115.56,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,134.82,70,,,percent of total billed charges,70% of total billed charges,144.45,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,147.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,86.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,134.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,92.45,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,173.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,173.34,
HEMOGLOBIN FRACTION QUANT,4083021,CDM,301,RC,83021,HCPCS,Outpatient,,,64.35,38.61,,63.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.21,350,,,Fee Schedule,350% of CMS OPPS Rate,18.42,102,,,Fee Schedule,102% of CMS OPPS Rate,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.06,100,,,Fee Schedule,100% of UHC Fee Schedule,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,41.53,230,,,Fee Schedule,230% of CMS OPPS Rate,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,63.93,
HISTAMINE,4083088,CDM,301,RC,83088,HCPCS,Outpatient,,,519.75,311.85,,104.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,363.83,70,,,percent of total billed charges,70% of total billed charges,389.81,75,,,percent of total billed charges,75% of total billed charges,53.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,415.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.35,350,,,Fee Schedule,350% of CMS OPPS Rate,30.12,102,,,Fee Schedule,102% of CMS OPPS Rate,397.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,233.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,363.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,311.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,100,,,Fee Schedule,100% of UHC Fee Schedule,363.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,230,,,Fee Schedule,230% of CMS OPPS Rate,249.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,467.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,100,,,Fee Schedule,100% of CMS OPPS Rate,29.53,467.78,
HOMOVANILLIC ACID,4083150,CDM,300,RC,83150,HCPCS,Outpatient,,,66.15,39.69,,79.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,40.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.43,350,,,Fee Schedule,350% of CMS OPPS Rate,22.85,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.5,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,51.54,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,22.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.5,79.33,
HISTOPLASMA CAPSUL  AG IA,4083200,CDM,306,RC,87385,HCPCS,Outpatient,,,186.3,111.78,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.41,70,,,percent of total billed charges,70% of total billed charges,139.73,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,142.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,83.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,130.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,89.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,167.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,167.67,
"HIV-1 ACCUQUANT, RNA, SER",4083250,CDM,306,RC,87536,HCPCS,Outpatient,,,255,153,,301.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,84.91,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,85.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,178.5,70,,,percent of total billed charges,70% of total billed charges,191.25,75,,,percent of total billed charges,75% of total billed charges,153.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.84,350,,,Fee Schedule,350% of CMS OPPS Rate,86.8,102,,,Fee Schedule,102% of CMS OPPS Rate,195.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,114.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,100,,,Fee Schedule,100% of UHC Fee Schedule,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,195.73,230,,,Fee Schedule,230% of CMS OPPS Rate,122.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,229.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,84.91,301.25,
HYDROXYPROGESTERONE-17,4083498,CDM,301,RC,83498,HCPCS,Outpatient,,,190.8,114.48,,96.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133.56,70,,,percent of total billed charges,70% of total billed charges,143.1,75,,,percent of total billed charges,75% of total billed charges,48.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.09,350,,,Fee Schedule,350% of CMS OPPS Rate,27.71,102,,,Fee Schedule,102% of CMS OPPS Rate,145.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,85.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.19,100,,,Fee Schedule,100% of UHC Fee Schedule,133.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,230,,,Fee Schedule,230% of CMS OPPS Rate,91.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,171.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of CMS OPPS Rate,27.17,171.72,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4083516,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
IMMUNOASSAY ANALYTE,4083520,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
"ANTIDEPRESSANTS, TRICYCLIC 1 OR 2",4083521,CDM,300,RC,80335,HCPCS,Outpatient,,,81,48.6,,,,,,Other,Not Separately reimbursable,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,72.9,
"INSULIN, FREE",4083527,CDM,301,RC,83527,HCPCS,Outpatient,,,190,114,,45.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,23.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.32,350,,,Fee Schedule,350% of CMS OPPS Rate,13.2,102,,,Fee Schedule,102% of CMS OPPS Rate,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,100,,,Fee Schedule,100% of UHC Fee Schedule,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,29.78,230,,,Fee Schedule,230% of CMS OPPS Rate,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,171,
INTERLEUKIN-6,4083529,CDM,300,RC,83529,HCPCS,Outpatient,,,183,109.8,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.5,50,,,percent of total billed charges,pays at 50% of total billed charges,128.1,70,,,percent of total billed charges,70% of total billed charges,137.25,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,146.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,140,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,82.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,91.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,87.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,164.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,164.7,
KETOSTEROIDS 17 OH,4083586,CDM,300,RC,83586,HCPCS,Outpatient,,,130,78,,45.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,91,70,,,percent of total billed charges,70% of total billed charges,97.5,75,,,percent of total billed charges,75% of total billed charges,23.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.8,350,,,Fee Schedule,350% of CMS OPPS Rate,13.05,102,,,Fee Schedule,102% of CMS OPPS Rate,99.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,58.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,14.22,100,,,Fee Schedule,100% of UHC Fee Schedule,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29.44,230,,,Fee Schedule,230% of CMS OPPS Rate,62.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,117,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.8,117,
ZINC (PROTOPORPHYRIN),4083602,CDM,301,RC,84202,HCPCS,Outpatient,,,35.5,21.3,,50.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,24.85,70,,,percent of total billed charges,70% of total billed charges,26.63,75,,,percent of total billed charges,75% of total billed charges,25.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,28.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.22,350,,,Fee Schedule,350% of CMS OPPS Rate,14.63,102,,,Fee Schedule,102% of CMS OPPS Rate,27.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of UHC Fee Schedule,24.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,33,230,,,Fee Schedule,230% of CMS OPPS Rate,17.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.35,50.79,
LIPOPROTEIN ELECTROPHORES,4083620,CDM,301,RC,83700,HCPCS,Outpatient,,,135.5,81.3,,39.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,20.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.41,350,,,Fee Schedule,350% of CMS OPPS Rate,11.48,102,,,Fee Schedule,102% of CMS OPPS Rate,103.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of UHC Fee Schedule,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.89,230,,,Fee Schedule,230% of CMS OPPS Rate,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,121.95,
LDH ISOENZYMES,4083625,CDM,300,RC,83625,HCPCS,Outpatient,,,117,70.2,,45.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,23.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.76,350,,,Fee Schedule,350% of CMS OPPS Rate,13.04,102,,,Fee Schedule,102% of CMS OPPS Rate,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.22,100,,,Fee Schedule,100% of UHC Fee Schedule,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,29.41,230,,,Fee Schedule,230% of CMS OPPS Rate,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,12.79,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,105.3,
LACTOFERRIN FECAL (QUAL),4083630,CDM,301,RC,83630,HCPCS,Outpatient,,,201,120.6,,69.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140.7,70,,,percent of total billed charges,70% of total billed charges,150.75,75,,,percent of total billed charges,75% of total billed charges,35.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,160.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.95,350,,,Fee Schedule,350% of CMS OPPS Rate,20.09,102,,,Fee Schedule,102% of CMS OPPS Rate,153.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,90.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,21.82,100,,,Fee Schedule,100% of UHC Fee Schedule,140.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,45.31,230,,,Fee Schedule,230% of CMS OPPS Rate,96.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,180.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,19.7,100,,,Fee Schedule,100% of CMS OPPS Rate,17.65,180.9,
LACTOFERRIN FECAL QUANTITATIVE,4083631,CDM,300,RC,83631,HCPCS,Outpatient,,,407,244.2,,69.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,284.9,70,,,percent of total billed charges,70% of total billed charges,305.25,75,,,percent of total billed charges,75% of total billed charges,35.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,325.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.7,350,,,Fee Schedule,350% of CMS OPPS Rate,20.02,102,,,Fee Schedule,102% of CMS OPPS Rate,311.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,183.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,284.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,244.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,21.82,100,,,Fee Schedule,100% of UHC Fee Schedule,284.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,45.14,230,,,Fee Schedule,230% of CMS OPPS Rate,195.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,366.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,366.3,
ASSAY LIPOPROTEIN PLA2,4083698,CDM,301,RC,83698,HCPCS,Outpatient,,,229.35,137.61,,163.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,46.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.55,70,,,percent of total billed charges,70% of total billed charges,172.01,75,,,percent of total billed charges,75% of total billed charges,83.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,162.08,350,,,Fee Schedule,350% of CMS OPPS Rate,47.23,102,,,Fee Schedule,102% of CMS OPPS Rate,175.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,103.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of UHC Fee Schedule,160.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,106.51,230,,,Fee Schedule,230% of CMS OPPS Rate,110.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,206.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.31,100,,,Fee Schedule,100% of CMS OPPS Rate,41.68,206.42,
NEONATAL SCREENING(PKUT4),4083700,CDM,301,RC,84030,HCPCS,Outpatient,,,121.95,73.17,,19.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges,91.46,75,,,percent of total billed charges,75% of total billed charges,9.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.25,350,,,Fee Schedule,350% of CMS OPPS Rate,5.61,102,,,Fee Schedule,102% of CMS OPPS Rate,93.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,6.11,100,,,Fee Schedule,100% of UHC Fee Schedule,85.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,12.65,230,,,Fee Schedule,230% of CMS OPPS Rate,58.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,109.76,
CD4(HELPER/INDUCER),4083703,CDM,302,RC,86360,HCPCS,Outpatient,,,141,84.6,,166.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.28,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges,105.75,75,,,percent of total billed charges,75% of total billed charges,84.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.43,350,,,Fee Schedule,350% of CMS OPPS Rate,47.91,102,,,Fee Schedule,102% of CMS OPPS Rate,107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,63.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.21,100,,,Fee Schedule,100% of UHC Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,108.05,230,,,Fee Schedule,230% of CMS OPPS Rate,67.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,166.3,
NEISSERIA GON. DIRECT PROBE,4083727,CDM,306,RC,87590,HCPCS,Outpatient,,,64,38.4,,95.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.8,70,,,percent of total billed charges,70% of total billed charges,48,75,,,percent of total billed charges,75% of total billed charges,48.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.08,350,,,Fee Schedule,350% of CMS OPPS Rate,27.41,102,,,Fee Schedule,102% of CMS OPPS Rate,48.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,28.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,24.19,100,,,Fee Schedule,100% of UHC Fee Schedule,44.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,61.82,230,,,Fee Schedule,230% of CMS OPPS Rate,30.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,57.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,26.88,100,,,Fee Schedule,100% of CMS OPPS Rate,24.19,95.15,
MANGANESE,4083785,CDM,301,RC,83785,HCPCS,Outpatient,,,54.5,32.7,,94.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.15,70,,,percent of total billed charges,70% of total billed charges,40.88,75,,,percent of total billed charges,75% of total billed charges,47.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.27,350,,,Fee Schedule,350% of CMS OPPS Rate,27.18,102,,,Fee Schedule,102% of CMS OPPS Rate,41.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,24.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,27.33,100,,,Fee Schedule,100% of UHC Fee Schedule,38.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,54.5,230,,,Fee Schedule,230% of CMS OPPS Rate,26.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,49.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,24.53,94.34,
METANEPHRINES,4083835,CDM,301,RC,83835,HCPCS,Outpatient,,,88,52.8,,59.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,30.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.29,350,,,Fee Schedule,350% of CMS OPPS Rate,17.27,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.83,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,79.2,
"MUCOPOLYSACCHARIDES, ACDI ON",4083864,CDM,300,RC,83864,HCPCS,Outpatient,,,530.5,318.3,,100.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,58.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,371.35,70,,,percent of total billed charges,70% of total billed charges,397.88,75,,,percent of total billed charges,75% of total billed charges,51.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,424.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,350,,,Fee Schedule,350% of CMS OPPS Rate,29.07,102,,,Fee Schedule,102% of CMS OPPS Rate,405.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,238.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,318.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,25.65,100,,,Fee Schedule,100% of UHC Fee Schedule,371.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,65.55,230,,,Fee Schedule,230% of CMS OPPS Rate,254.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,477.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,28.5,100,,,Fee Schedule,100% of CMS OPPS Rate,25.61,477.45,
"MUCIN, SYNOVIAL FLUID",4083872,CDM,301,RC,83872,HCPCS,Outpatient,,,43,25.8,,20.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,10.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.51,350,,,Fee Schedule,350% of CMS OPPS Rate,5.97,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6.52,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,13.47,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5.81,38.7,
CARDIO IQ R MYELOPEROXIDASE,4083876,CDM,300,RC,83876,HCPCS,Outpatient,,,116.4,69.84,,180.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.82,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,50.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,103.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.48,70,,,percent of total billed charges,70% of total billed charges,87.3,75,,,percent of total billed charges,75% of total billed charges,91.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,178.01,350,,,Fee Schedule,350% of CMS OPPS Rate,51.87,102,,,Fee Schedule,102% of CMS OPPS Rate,89.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,52.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,100,,,Fee Schedule,100% of UHC Fee Schedule,81.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,116.4,230,,,Fee Schedule,230% of CMS OPPS Rate,55.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,104.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,100,,,Fee Schedule,100% of CMS OPPS Rate,18.82,180.04,
NEPHELOMETRY EA,4083883,CDM,300,RC,83883,HCPCS,Outpatient,,,41,24.6,,48.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,24.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.87,102,,,Fee Schedule,102% of CMS OPPS Rate,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of UHC Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,230,,,Fee Schedule,230% of CMS OPPS Rate,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,48.14,
ALKALOIDS OTHER,4083887,CDM,301,RC,80323,HCPCS,Outpatient,,,216,129.6,,,,,,Other,Not Separately reimbursable,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,194.4,
GABAPENTIN (NEURONTIN),4083905,CDM,301,RC,80171,HCPCS,Outpatient,,,88.65,53.19,,76.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.84,350,,,Fee Schedule,350% of CMS OPPS Rate,22.1,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,19.5,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,49.84,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,79.79,
NUCLEOTIDASE-5-,4083915,CDM,301,RC,83915,HCPCS,Outpatient,,,128,76.8,,39.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.08,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,20.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.02,350,,,Fee Schedule,350% of CMS OPPS Rate,11.37,102,,,Fee Schedule,102% of CMS OPPS Rate,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of UHC Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,25.64,230,,,Fee Schedule,230% of CMS OPPS Rate,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,100,,,Fee Schedule,100% of CMS OPPS Rate,11.15,115.2,
ORGANIC ACID QUANT,4083918,CDM,300,RC,83918,HCPCS,Outpatient,,,276.75,166.05,,83.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,23.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.73,70,,,percent of total billed charges,70% of total billed charges,207.56,75,,,percent of total billed charges,75% of total billed charges,42.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,221.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.6,350,,,Fee Schedule,350% of CMS OPPS Rate,24.07,102,,,Fee Schedule,102% of CMS OPPS Rate,211.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,124.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21.24,100,,,Fee Schedule,100% of UHC Fee Schedule,193.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,54.28,230,,,Fee Schedule,230% of CMS OPPS Rate,132.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,249.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21.18,249.08,
"ORGANIC ACID SINGLE, QUAN",4083921,CDM,301,RC,83921,HCPCS,Outpatient,,,92.4,55.44,,75.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.68,70,,,percent of total billed charges,70% of total billed charges,69.3,75,,,percent of total billed charges,75% of total billed charges,38.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.23,350,,,Fee Schedule,350% of CMS OPPS Rate,21.63,102,,,Fee Schedule,102% of CMS OPPS Rate,70.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,41.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,100,,,Fee Schedule,100% of UHC Fee Schedule,64.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,48.78,230,,,Fee Schedule,230% of CMS OPPS Rate,44.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,83.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,83.16,
OSTEOCALCIN BONE PROTEIN,4083937,CDM,301,RC,83937,HCPCS,Outpatient,,,258,154.8,,105.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.6,70,,,percent of total billed charges,70% of total billed charges,193.5,75,,,percent of total billed charges,75% of total billed charges,53.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.47,350,,,Fee Schedule,350% of CMS OPPS Rate,30.44,102,,,Fee Schedule,102% of CMS OPPS Rate,197.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,116.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,33.17,100,,,Fee Schedule,100% of UHC Fee Schedule,180.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,68.65,230,,,Fee Schedule,230% of CMS OPPS Rate,123.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,232.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,100,,,Fee Schedule,100% of CMS OPPS Rate,29.85,232.2,
ONCOPROTEIN DCP,4083951,CDM,301,RC,83951,HCPCS,Outpatient,,,550,330,,228.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,64.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,162.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,385,70,,,percent of total billed charges,70% of total billed charges,412.5,75,,,percent of total billed charges,75% of total billed charges,115.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.43,350,,,Fee Schedule,350% of CMS OPPS Rate,65.69,102,,,Fee Schedule,102% of CMS OPPS Rate,420.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,71.57,100,,,Fee Schedule,100% of UHC Fee Schedule,385,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,148.14,230,,,Fee Schedule,230% of CMS OPPS Rate,264,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,495,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,100,,,Fee Schedule,100% of CMS OPPS Rate,64.41,495,
"ORGANIC ACID,SERUM",4083952,CDM,301,RC,83919,HCPCS,Outpatient,,,301.5,180.9,,58.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,211.05,70,,,percent of total billed charges,70% of total billed charges,226.13,75,,,percent of total billed charges,75% of total billed charges,29.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.57,350,,,Fee Schedule,350% of CMS OPPS Rate,16.77,102,,,Fee Schedule,102% of CMS OPPS Rate,230.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,135.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of UHC Fee Schedule,211.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,37.83,230,,,Fee Schedule,230% of CMS OPPS Rate,144.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,271.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,271.35,
PHENCYCLIDINE PCP CONFIRM,4083992,CDM,301,RC,83992,HCPCS,Outpatient,,,126,75.6,,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,100,,,Fee Schedule,100% of UHC Fee Schedule,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,113.4,
ASSAY CALPROTECTIN FECAL,4083993,CDM,301,RC,83993,HCPCS,Outpatient,,,205,123,,69.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.63,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,153.75,75,,,percent of total billed charges,75% of total billed charges,35.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,164,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.7,350,,,Fee Schedule,350% of CMS OPPS Rate,20.02,102,,,Fee Schedule,102% of CMS OPPS Rate,156.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,92.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,21.82,100,,,Fee Schedule,100% of UHC Fee Schedule,143.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,45.14,230,,,Fee Schedule,230% of CMS OPPS Rate,98.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,184.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.63,184.5,
ALK PHOS ISOENZYMES,4084080,CDM,301,RC,84080,HCPCS,Outpatient,,,129.25,77.55,,52.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.48,70,,,percent of total billed charges,70% of total billed charges,96.94,75,,,percent of total billed charges,75% of total billed charges,26.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.73,350,,,Fee Schedule,350% of CMS OPPS Rate,15.07,102,,,Fee Schedule,102% of CMS OPPS Rate,98.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of UHC Fee Schedule,90.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,33.99,230,,,Fee Schedule,230% of CMS OPPS Rate,62.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,116.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,116.33,
PORPHOBILINOGEN-URINE-24H,4084110,CDM,301,RC,84110,HCPCS,Outpatient,,,103.95,62.37,,29.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges,77.96,75,,,percent of total billed charges,75% of total billed charges,15.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.54,350,,,Fee Schedule,350% of CMS OPPS Rate,8.6,102,,,Fee Schedule,102% of CMS OPPS Rate,79.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,9.38,100,,,Fee Schedule,100% of UHC Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,19.41,230,,,Fee Schedule,230% of CMS OPPS Rate,49.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,93.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,100,,,Fee Schedule,100% of CMS OPPS Rate,6,93.56,
PORPHYRINS-QUANT-URINE24H,4084120,CDM,301,RC,84120,HCPCS,Outpatient,,,214,128.4,,52.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.71,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,26.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.48,350,,,Fee Schedule,350% of CMS OPPS Rate,15,102,,,Fee Schedule,102% of CMS OPPS Rate,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of UHC Fee Schedule,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,33.83,230,,,Fee Schedule,230% of CMS OPPS Rate,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,192.6,
PREGNENOLONE,4084140,CDM,301,RC,84140,HCPCS,Outpatient,,,140.66,84.4,,73.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.46,70,,,percent of total billed charges,70% of total billed charges,105.5,75,,,percent of total billed charges,75% of total billed charges,37.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.34,350,,,Fee Schedule,350% of CMS OPPS Rate,21.08,102,,,Fee Schedule,102% of CMS OPPS Rate,107.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,63.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.97,100,,,Fee Schedule,100% of UHC Fee Schedule,98.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,47.54,230,,,Fee Schedule,230% of CMS OPPS Rate,67.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,126.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,100,,,Fee Schedule,100% of CMS OPPS Rate,20.67,126.59,
PRIMIDONE,4084141,CDM,301,RC,80188,HCPCS,Outpatient,,,138.15,82.89,,58.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.71,70,,,percent of total billed charges,70% of total billed charges,103.61,75,,,percent of total billed charges,75% of total billed charges,29.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.06,350,,,Fee Schedule,350% of CMS OPPS Rate,16.92,102,,,Fee Schedule,102% of CMS OPPS Rate,105.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,62.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of UHC Fee Schedule,96.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,230,,,Fee Schedule,230% of CMS OPPS Rate,66.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,124.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,124.34,
"PROTEIN, WESTERN BLOT W INTERP",4084181,CDM,300,RC,84181,HCPCS,Outpatient,,,490,294,,60.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,343,70,,,percent of total billed charges,70% of total billed charges,367.5,75,,,percent of total billed charges,75% of total billed charges,30.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.6,350,,,Fee Schedule,350% of CMS OPPS Rate,17.37,102,,,Fee Schedule,102% of CMS OPPS Rate,374.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,220.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,343,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,18.92,100,,,Fee Schedule,100% of UHC Fee Schedule,343,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,39.16,230,,,Fee Schedule,230% of CMS OPPS Rate,235.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,441,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,441,
PROINSULIN,4084206,CDM,301,RC,84206,HCPCS,Outpatient,,,46.8,28.08,,94.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.76,70,,,percent of total billed charges,70% of total billed charges,35.1,75,,,percent of total billed charges,75% of total billed charges,48.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.41,350,,,Fee Schedule,350% of CMS OPPS Rate,27.22,102,,,Fee Schedule,102% of CMS OPPS Rate,35.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,24.02,100,,,Fee Schedule,100% of UHC Fee Schedule,32.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,230,,,Fee Schedule,230% of CMS OPPS Rate,22.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,42.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,26.69,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,94.48,
PYRUVATE,4084210,CDM,301,RC,84210,HCPCS,Outpatient,,,266.6,159.96,,51.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,186.62,70,,,percent of total billed charges,70% of total billed charges,199.95,75,,,percent of total billed charges,75% of total billed charges,26.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,213.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.68,350,,,Fee Schedule,350% of CMS OPPS Rate,14.76,102,,,Fee Schedule,102% of CMS OPPS Rate,203.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,119.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of UHC Fee Schedule,186.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,33.3,230,,,Fee Schedule,230% of CMS OPPS Rate,127.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,239.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.48,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,239.94,
RECEPTOR ASSAY NON ENDOCRINE,4084238,CDM,301,RC,84238,HCPCS,Outpatient,,,440,264,,129.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,92.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,65.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.99,350,,,Fee Schedule,350% of CMS OPPS Rate,37.3,102,,,Fee Schedule,102% of CMS OPPS Rate,336.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,40.63,100,,,Fee Schedule,100% of UHC Fee Schedule,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,84.11,230,,,Fee Schedule,230% of CMS OPPS Rate,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,396,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,100,,,Fee Schedule,100% of CMS OPPS Rate,36.57,396,
RENIN,4084244,CDM,301,RC,84244,HCPCS,Outpatient,,,366.3,219.78,,77.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.41,70,,,percent of total billed charges,70% of total billed charges,274.73,75,,,percent of total billed charges,75% of total billed charges,39.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,293.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.96,350,,,Fee Schedule,350% of CMS OPPS Rate,22.42,102,,,Fee Schedule,102% of CMS OPPS Rate,280.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,164.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,100,,,Fee Schedule,100% of UHC Fee Schedule,256.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,50.57,230,,,Fee Schedule,230% of CMS OPPS Rate,175.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,329.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,329.67,
RIBOFLAVIN (VITABMIN B2),4084252,CDM,301,RC,84252,HCPCS,Outpatient,,,276,165.6,,71.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.2,70,,,percent of total billed charges,70% of total billed charges,207,75,,,percent of total billed charges,75% of total billed charges,36.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.83,350,,,Fee Schedule,350% of CMS OPPS Rate,20.64,102,,,Fee Schedule,102% of CMS OPPS Rate,211.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,124.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.48,100,,,Fee Schedule,100% of UHC Fee Schedule,193.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,46.55,230,,,Fee Schedule,230% of CMS OPPS Rate,132.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,248.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,20.23,100,,,Fee Schedule,100% of CMS OPPS Rate,13.58,248.4,
SELENIUM,4084255,CDM,300,RC,84255,HCPCS,Outpatient,,,106,63.6,,90.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,45.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.35,350,,,Fee Schedule,350% of CMS OPPS Rate,26.04,102,,,Fee Schedule,102% of CMS OPPS Rate,81.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,100,,,Fee Schedule,100% of UHC Fee Schedule,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,58.71,230,,,Fee Schedule,230% of CMS OPPS Rate,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,100,,,Fee Schedule,100% of CMS OPPS Rate,25.53,95.4,
SEROTONIN,4084260,CDM,301,RC,84260,HCPCS,Outpatient,,,555.5,333.3,,109.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,30.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,388.85,70,,,percent of total billed charges,70% of total billed charges,416.63,75,,,percent of total billed charges,75% of total billed charges,55.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,444.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.43,350,,,Fee Schedule,350% of CMS OPPS Rate,31.59,102,,,Fee Schedule,102% of CMS OPPS Rate,424.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,249.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,388.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,333.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,100,,,Fee Schedule,100% of UHC Fee Schedule,388.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,71.25,230,,,Fee Schedule,230% of CMS OPPS Rate,266.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,499.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,100,,,Fee Schedule,100% of CMS OPPS Rate,30.98,499.95,
SEX HORMONE BINDING GLOB.,4084270,CDM,300,RC,84270,HCPCS,Outpatient,,,70.4,42.24,,76.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49.28,70,,,percent of total billed charges,70% of total billed charges,52.8,75,,,percent of total billed charges,75% of total billed charges,39.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.05,350,,,Fee Schedule,350% of CMS OPPS Rate,22.16,102,,,Fee Schedule,102% of CMS OPPS Rate,53.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,100,,,Fee Schedule,100% of UHC Fee Schedule,49.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,49.97,230,,,Fee Schedule,230% of CMS OPPS Rate,33.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,63.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.24,76.92,
SOMATOMEDIN(GROWTH FACT),4084305,CDM,300,RC,84305,HCPCS,Outpatient,,,271,162.6,,75.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,189.7,70,,,percent of total billed charges,70% of total billed charges,203.25,75,,,percent of total billed charges,75% of total billed charges,38.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,216.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.41,350,,,Fee Schedule,350% of CMS OPPS Rate,21.68,102,,,Fee Schedule,102% of CMS OPPS Rate,207.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,121.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,100,,,Fee Schedule,100% of UHC Fee Schedule,189.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,48.89,230,,,Fee Schedule,230% of CMS OPPS Rate,130.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,243.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,100,,,Fee Schedule,100% of CMS OPPS Rate,21.26,243.9,
SOMATOSTATIN,4084307,CDM,301,RC,84307,HCPCS,Outpatient,,,194,116.4,,64.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.8,70,,,percent of total billed charges,70% of total billed charges,145.5,75,,,percent of total billed charges,75% of total billed charges,32.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.98,350,,,Fee Schedule,350% of CMS OPPS Rate,18.64,102,,,Fee Schedule,102% of CMS OPPS Rate,148.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,87.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,20.3,100,,,Fee Schedule,100% of UHC Fee Schedule,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,42.04,230,,,Fee Schedule,230% of CMS OPPS Rate,93.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,100,,,Fee Schedule,100% of CMS OPPS Rate,18.28,174.6,
SUGARS MULTIPLE QL EA SPECIMEN,4084377,CDM,300,RC,84377,HCPCS,Outpatient,,,256.3,153.78,,19.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.41,70,,,percent of total billed charges,70% of total billed charges,192.23,75,,,percent of total billed charges,75% of total billed charges,9.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,205.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.25,350,,,Fee Schedule,350% of CMS OPPS Rate,5.61,102,,,Fee Schedule,102% of CMS OPPS Rate,196.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,115.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,6.11,100,,,Fee Schedule,100% of UHC Fee Schedule,179.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,12.65,230,,,Fee Schedule,230% of CMS OPPS Rate,123.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,230.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,230.67,
SULFATE URINE,4084392,CDM,301,RC,84392,HCPCS,Outpatient,,,16,9.6,,19.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,9.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.21,350,,,Fee Schedule,350% of CMS OPPS Rate,5.59,102,,,Fee Schedule,102% of CMS OPPS Rate,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,230,,,Fee Schedule,230% of CMS OPPS Rate,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,19.43,
Blood test to evaluate thyroid function,4084480,CDM,301,RC,84480,HCPCS,Outpatient,,,136.4,81.84,,50.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,95.48,70,,,percent of total billed charges,70% of total billed charges,102.3,75,,,percent of total billed charges,75% of total billed charges,25.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.63,350,,,Fee Schedule,350% of CMS OPPS Rate,14.46,102,,,Fee Schedule,102% of CMS OPPS Rate,104.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of UHC Fee Schedule,95.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,230,,,Fee Schedule,230% of CMS OPPS Rate,65.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,122.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,7.83,122.76,
"T3, REVERSE",4084482,CDM,301,RC,84482,HCPCS,Outpatient,,,92.4,55.44,,55.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.68,70,,,percent of total billed charges,70% of total billed charges,69.3,75,,,percent of total billed charges,75% of total billed charges,28.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.16,350,,,Fee Schedule,350% of CMS OPPS Rate,16.07,102,,,Fee Schedule,102% of CMS OPPS Rate,70.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,17.51,100,,,Fee Schedule,100% of UHC Fee Schedule,64.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,36.24,230,,,Fee Schedule,230% of CMS OPPS Rate,44.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,83.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.69,83.16,
VMA-URINE-24 HOUR,4084585,CDM,301,RC,84585,HCPCS,Outpatient,,,135,81,,54.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,27.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.25,350,,,Fee Schedule,350% of CMS OPPS Rate,15.81,102,,,Fee Schedule,102% of CMS OPPS Rate,103.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of UHC Fee Schedule,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,230,,,Fee Schedule,230% of CMS OPPS Rate,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,121.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15.5,121.5,
ADH-ANTI DIURETIC HOR,4084588,CDM,301,RC,84588,HCPCS,Outpatient,,,99.55,59.73,,120.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,33.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.69,70,,,percent of total billed charges,70% of total billed charges,74.66,75,,,percent of total billed charges,75% of total billed charges,61.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.79,350,,,Fee Schedule,350% of CMS OPPS Rate,34.61,102,,,Fee Schedule,102% of CMS OPPS Rate,76.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,44.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of UHC Fee Schedule,69.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,78.06,230,,,Fee Schedule,230% of CMS OPPS Rate,47.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,89.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.3,120.14,
VITAMIN K,4084597,CDM,301,RC,84597,HCPCS,Outpatient,,,169.4,101.64,,48.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.54,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.58,70,,,percent of total billed charges,70% of total billed charges,127.05,75,,,percent of total billed charges,75% of total billed charges,24.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.02,350,,,Fee Schedule,350% of CMS OPPS Rate,13.99,102,,,Fee Schedule,102% of CMS OPPS Rate,129.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,76.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,15.25,100,,,Fee Schedule,100% of UHC Fee Schedule,118.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,31.55,230,,,Fee Schedule,230% of CMS OPPS Rate,81.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,152.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,13.72,100,,,Fee Schedule,100% of CMS OPPS Rate,10.25,152.46,
"ANTI-CMV AB,IGM",4085005,CDM,302,RC,86645,HCPCS,Outpatient,,,106.15,63.69,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,95.54,
HEPATITIS B CORE IGM AB,4085010,CDM,302,RC,86705,HCPCS,Outpatient,,,67.82,40.69,,41.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.47,70,,,percent of total billed charges,70% of total billed charges,50.87,75,,,percent of total billed charges,75% of total billed charges,21.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.19,350,,,Fee Schedule,350% of CMS OPPS Rate,12,102,,,Fee Schedule,102% of CMS OPPS Rate,51.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,30.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,13.09,100,,,Fee Schedule,100% of UHC Fee Schedule,47.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,27.07,230,,,Fee Schedule,230% of CMS OPPS Rate,32.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,61.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.77,61.04,
ANTI -HEPATITIS A AB IGM,4085015,CDM,302,RC,86709,HCPCS,Outpatient,,,57.42,34.45,,39.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.19,70,,,percent of total billed charges,70% of total billed charges,43.07,75,,,percent of total billed charges,75% of total billed charges,20.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,45.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.41,350,,,Fee Schedule,350% of CMS OPPS Rate,11.48,102,,,Fee Schedule,102% of CMS OPPS Rate,43.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of UHC Fee Schedule,40.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,25.89,230,,,Fee Schedule,230% of CMS OPPS Rate,27.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,51.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,51.68,
"C-PEPTIDE, SERUM",4085045,CDM,301,RC,84681,HCPCS,Outpatient,,,89.1,53.46,,73.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,37.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,350,,,Fee Schedule,350% of CMS OPPS Rate,21.22,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.86,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,13.96,80.19,
Blood test to determine the concentration of lead in the blood,4085075,CDM,301,RC,83655,HCPCS,Outpatient,,,58,34.8,,42.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,21.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.38,350,,,Fee Schedule,350% of CMS OPPS Rate,12.35,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,13.46,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,52.2,
LUPUS ANTICOAGULANT,4085080,CDM,305,RC,85613,HCPCS,Outpatient,,,68.2,40.92,,33.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges,51.15,75,,,percent of total billed charges,75% of total billed charges,17.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.53,350,,,Fee Schedule,350% of CMS OPPS Rate,9.77,102,,,Fee Schedule,102% of CMS OPPS Rate,52.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,30.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of UHC Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,22.03,230,,,Fee Schedule,230% of CMS OPPS Rate,32.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,61.38,
Blood test to determine if antibodies exist for measles,4085085,CDM,302,RC,86765,HCPCS,Outpatient,,,62,37.2,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,55.8,
"OXALATE, URINE",4085110,CDM,301,RC,83945,HCPCS,Outpatient,,,194.15,116.49,,51.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.91,70,,,percent of total billed charges,70% of total billed charges,145.61,75,,,percent of total billed charges,75% of total billed charges,26.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,155.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.57,350,,,Fee Schedule,350% of CMS OPPS Rate,14.73,102,,,Fee Schedule,102% of CMS OPPS Rate,148.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,87.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,135.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.23,230,,,Fee Schedule,230% of CMS OPPS Rate,93.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,174.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,174.74,
PARVOVIRUS AB  EA,4085115,CDM,302,RC,86747,HCPCS,Outpatient,,,56.65,33.99,,53.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.66,70,,,percent of total billed charges,70% of total billed charges,42.49,75,,,percent of total billed charges,75% of total billed charges,27.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.6,350,,,Fee Schedule,350% of CMS OPPS Rate,15.33,102,,,Fee Schedule,102% of CMS OPPS Rate,43.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,100% of UHC Fee Schedule,39.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.56,230,,,Fee Schedule,230% of CMS OPPS Rate,27.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,53.2,
"PROTEIN C, PLASMA",4085130,CDM,305,RC,85303,HCPCS,Outpatient,,,193.95,116.37,,48.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.77,70,,,percent of total billed charges,70% of total billed charges,145.46,75,,,percent of total billed charges,75% of total billed charges,24.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,155.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.44,350,,,Fee Schedule,350% of CMS OPPS Rate,14.11,102,,,Fee Schedule,102% of CMS OPPS Rate,148.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,87.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.37,100,,,Fee Schedule,100% of UHC Fee Schedule,135.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,31.83,230,,,Fee Schedule,230% of CMS OPPS Rate,93.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,174.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,174.56,
PROTEIN S PLASMA,4085135,CDM,305,RC,85306,HCPCS,Outpatient,,,200.25,120.15,,54.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140.18,70,,,percent of total billed charges,70% of total billed charges,150.19,75,,,percent of total billed charges,75% of total billed charges,27.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,160.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.62,350,,,Fee Schedule,350% of CMS OPPS Rate,15.62,102,,,Fee Schedule,102% of CMS OPPS Rate,153.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,90.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of UHC Fee Schedule,140.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,35.23,230,,,Fee Schedule,230% of CMS OPPS Rate,96.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,180.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,180.23,
"THYROID BIND GLOBN, SER",4085150,CDM,301,RC,84442,HCPCS,Outpatient,,,76.5,45.9,,52.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.55,70,,,percent of total billed charges,70% of total billed charges,57.38,75,,,percent of total billed charges,75% of total billed charges,26.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.73,350,,,Fee Schedule,350% of CMS OPPS Rate,15.07,102,,,Fee Schedule,102% of CMS OPPS Rate,58.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of UHC Fee Schedule,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,33.99,230,,,Fee Schedule,230% of CMS OPPS Rate,36.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,68.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.78,68.85,
"VITAMIN B 1, SERUM",4085155,CDM,301,RC,84425,HCPCS,Outpatient,,,138.6,83.16,,75.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.23,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges,103.95,75,,,percent of total billed charges,75% of total billed charges,38.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.3,350,,,Fee Schedule,350% of CMS OPPS Rate,21.65,102,,,Fee Schedule,102% of CMS OPPS Rate,106.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,23.59,100,,,Fee Schedule,100% of UHC Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,48.82,230,,,Fee Schedule,230% of CMS OPPS Rate,66.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,100,,,Fee Schedule,100% of CMS OPPS Rate,21.23,124.74,
VON WILLEBRAND FACT AG,4085160,CDM,305,RC,85246,HCPCS,Outpatient,,,193.05,115.83,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,173.75,
OLIGOCL IMMGLOB (MS PNL),4085215,CDM,301,RC,83916,HCPCS,Outpatient,,,82,49.2,,96.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,49.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.86,350,,,Fee Schedule,350% of CMS OPPS Rate,27.93,102,,,Fee Schedule,102% of CMS OPPS Rate,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of UHC Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,62.99,230,,,Fee Schedule,230% of CMS OPPS Rate,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.12,96.96,
MYELIN BASIC PROTEIN,4085220,CDM,301,RC,83873,HCPCS,Outpatient,,,52,31.2,,60.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.4,70,,,percent of total billed charges,70% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,30.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.2,350,,,Fee Schedule,350% of CMS OPPS Rate,17.54,102,,,Fee Schedule,102% of CMS OPPS Rate,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,19.12,100,,,Fee Schedule,100% of UHC Fee Schedule,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,39.56,230,,,Fee Schedule,230% of CMS OPPS Rate,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,60.88,
FACTOR VII ACTIVITY,4085230,CDM,305,RC,85230,HCPCS,Outpatient,,,101.75,61.05,,63.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.23,70,,,percent of total billed charges,70% of total billed charges,76.31,75,,,percent of total billed charges,75% of total billed charges,32.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.64,350,,,Fee Schedule,350% of CMS OPPS Rate,18.25,102,,,Fee Schedule,102% of CMS OPPS Rate,77.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,100,,,Fee Schedule,100% of UHC Fee Schedule,71.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.17,230,,,Fee Schedule,230% of CMS OPPS Rate,48.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,91.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,91.58,
CLOTTING FACTOR VIII ANTIGEN,4085244,CDM,305,RC,85244,HCPCS,Outpatient,,,360,216,,72.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,252,70,,,percent of total billed charges,70% of total billed charges,270,75,,,percent of total billed charges,75% of total billed charges,36.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.47,350,,,Fee Schedule,350% of CMS OPPS Rate,20.82,102,,,Fee Schedule,102% of CMS OPPS Rate,275.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,162,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of UHC Fee Schedule,252,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,46.96,230,,,Fee Schedule,230% of CMS OPPS Rate,172.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,324,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,100,,,Fee Schedule,100% of CMS OPPS Rate,20.42,324,
FACTOR X ACTIVITY,4085260,CDM,305,RC,85260,HCPCS,Outpatient,,,92.5,55.5,,63.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.75,70,,,percent of total billed charges,70% of total billed charges,69.38,75,,,percent of total billed charges,75% of total billed charges,32.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.64,350,,,Fee Schedule,350% of CMS OPPS Rate,18.25,102,,,Fee Schedule,102% of CMS OPPS Rate,70.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,100,,,Fee Schedule,100% of UHC Fee Schedule,64.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.17,230,,,Fee Schedule,230% of CMS OPPS Rate,44.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,83.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,83.25,
FACTOR XI,4085270,CDM,300,RC,85270,HCPCS,Outpatient,,,95.4,57.24,,63.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.78,70,,,percent of total billed charges,70% of total billed charges,71.55,75,,,percent of total billed charges,75% of total billed charges,32.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.64,350,,,Fee Schedule,350% of CMS OPPS Rate,18.25,102,,,Fee Schedule,102% of CMS OPPS Rate,72.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,42.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,100,,,Fee Schedule,100% of UHC Fee Schedule,66.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.17,230,,,Fee Schedule,230% of CMS OPPS Rate,45.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,85.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,85.86,
FACTOR XII,4085280,CDM,300,RC,85280,HCPCS,Outpatient,,,95.4,57.24,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.78,70,,,percent of total billed charges,70% of total billed charges,71.55,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,72.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,42.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.5,100,,,Fee Schedule,100% of UHC Fee Schedule,66.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,45.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,85.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,85.86,
CLOTTING FACTOR XIII,4085290,CDM,305,RC,85290,HCPCS,Outpatient,,,426,255.6,,57.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,298.2,70,,,percent of total billed charges,70% of total billed charges,319.5,75,,,percent of total billed charges,75% of total billed charges,29.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.19,350,,,Fee Schedule,350% of CMS OPPS Rate,16.66,102,,,Fee Schedule,102% of CMS OPPS Rate,325.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,191.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,298.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,18.15,100,,,Fee Schedule,100% of UHC Fee Schedule,298.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,37.58,230,,,Fee Schedule,230% of CMS OPPS Rate,204.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,383.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,100,,,Fee Schedule,100% of CMS OPPS Rate,16.34,383.4,
CLOTTING FACTOR XIII SCRN SOLUBILITY,4085291,CDM,305,RC,85291,HCPCS,Outpatient,,,129.2,77.52,,32.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.44,70,,,percent of total billed charges,70% of total billed charges,96.9,75,,,percent of total billed charges,75% of total billed charges,16.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.88,350,,,Fee Schedule,350% of CMS OPPS Rate,9.29,102,,,Fee Schedule,102% of CMS OPPS Rate,98.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,58.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.88,100,,,Fee Schedule,100% of UHC Fee Schedule,90.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,20.95,230,,,Fee Schedule,230% of CMS OPPS Rate,62.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,116.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,100,,,Fee Schedule,100% of CMS OPPS Rate,9.11,116.28,
CLOTTING INHIBITORS,4085300,CDM,305,RC,85300,HCPCS,Outpatient,,,36,21.6,,41.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges,27,75,,,percent of total billed charges,75% of total billed charges,21.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.47,350,,,Fee Schedule,350% of CMS OPPS Rate,12.08,102,,,Fee Schedule,102% of CMS OPPS Rate,27.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.17,100,,,Fee Schedule,100% of UHC Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.25,230,,,Fee Schedule,230% of CMS OPPS Rate,17.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,41.94,
ANTITHROMBIN III,4085301,CDM,305,RC,85301,HCPCS,Outpatient,,,152.1,91.26,,38.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,19.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.83,350,,,Fee Schedule,350% of CMS OPPS Rate,11.02,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,24.86,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,136.89,
CLOTTING INHIBI PROTEIN C AG,4085302,CDM,305,RC,85302,HCPCS,Outpatient,,,108.48,65.09,,42.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.94,70,,,percent of total billed charges,70% of total billed charges,81.36,75,,,percent of total billed charges,75% of total billed charges,21.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.03,350,,,Fee Schedule,350% of CMS OPPS Rate,12.25,102,,,Fee Schedule,102% of CMS OPPS Rate,82.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,48.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of UHC Fee Schedule,75.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,27.62,230,,,Fee Schedule,230% of CMS OPPS Rate,52.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,97.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,97.63,
"PROTEIN S AG, TOTAL",4085305,CDM,305,RC,85305,HCPCS,Outpatient,,,65.25,39.15,,41.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.68,70,,,percent of total billed charges,70% of total billed charges,48.94,75,,,percent of total billed charges,75% of total billed charges,20.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.63,350,,,Fee Schedule,350% of CMS OPPS Rate,11.84,102,,,Fee Schedule,102% of CMS OPPS Rate,49.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,29.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,12.9,100,,,Fee Schedule,100% of UHC Fee Schedule,45.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,26.7,230,,,Fee Schedule,230% of CMS OPPS Rate,31.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,58.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,58.73,
ACTIVATED PROTEIN C RESISTANCE,4085307,CDM,305,RC,85307,HCPCS,Outpatient,,,194,116.4,,54.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.8,70,,,percent of total billed charges,70% of total billed charges,145.5,75,,,percent of total billed charges,75% of total billed charges,27.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.62,350,,,Fee Schedule,350% of CMS OPPS Rate,15.62,102,,,Fee Schedule,102% of CMS OPPS Rate,148.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,87.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of UHC Fee Schedule,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,35.23,230,,,Fee Schedule,230% of CMS OPPS Rate,93.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,174.6,
COMPLEMENT AG,4085312,CDM,302,RC,86160,HCPCS,Outpatient,,,44,26.4,,42.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,21.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,350,,,Fee Schedule,350% of CMS OPPS Rate,12.24,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,100% of UHC Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,27.6,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,42.48,
ANTIBODY ID LEUKOCYTE ABS,4085334,CDM,302,RC,86021,HCPCS,Outpatient,,,54.45,32.67,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
"ANDROSTENEDIONE, SERUM",4085344,CDM,301,RC,82157,HCPCS,Outpatient,,,138.15,82.89,,103.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.71,70,,,percent of total billed charges,70% of total billed charges,103.61,75,,,percent of total billed charges,75% of total billed charges,52.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.48,350,,,Fee Schedule,350% of CMS OPPS Rate,29.86,102,,,Fee Schedule,102% of CMS OPPS Rate,105.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,62.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,32.53,100,,,Fee Schedule,100% of UHC Fee Schedule,96.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,67.34,230,,,Fee Schedule,230% of CMS OPPS Rate,66.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,124.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,100,,,Fee Schedule,100% of CMS OPPS Rate,29.28,124.34,
ANTI-LEPTOSPIRA AB,4085346,CDM,302,RC,86720,HCPCS,Outpatient,,,148,88.8,,57.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,103.6,70,,,percent of total billed charges,70% of total billed charges,111,75,,,percent of total billed charges,75% of total billed charges,29.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.7,350,,,Fee Schedule,350% of CMS OPPS Rate,16.52,102,,,Fee Schedule,102% of CMS OPPS Rate,113.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,66.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,103.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,103.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,37.26,230,,,Fee Schedule,230% of CMS OPPS Rate,71.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,133.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,133.2,
HEP B SURFACE AG,4085350,CDM,306,RC,87340,HCPCS,Outpatient,,,169.2,101.52,,36.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.44,70,,,percent of total billed charges,70% of total billed charges,126.9,75,,,percent of total billed charges,75% of total billed charges,18.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.15,350,,,Fee Schedule,350% of CMS OPPS Rate,10.53,102,,,Fee Schedule,102% of CMS OPPS Rate,129.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,76.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,100,,,Fee Schedule,100% of UHC Fee Schedule,118.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.75,230,,,Fee Schedule,230% of CMS OPPS Rate,81.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,152.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,152.28,
Blood test indicating infection with Hepatitis B,4085354,CDM,302,RC,86704,HCPCS,Outpatient,,,188.1,112.86,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges,141.08,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,150.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,143.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,90.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,169.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,169.29,
HEP B SURFACE AB,4085356,CDM,302,RC,86706,HCPCS,Outpatient,,,190.85,114.51,,38.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,133.6,70,,,percent of total billed charges,70% of total billed charges,143.14,75,,,percent of total billed charges,75% of total billed charges,19.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.59,350,,,Fee Schedule,350% of CMS OPPS Rate,10.95,102,,,Fee Schedule,102% of CMS OPPS Rate,146,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,85.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of UHC Fee Schedule,133.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.7,230,,,Fee Schedule,230% of CMS OPPS Rate,91.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,171.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,171.77,
Blood test indicating infection with Hepatitis A,4085362,CDM,302,RC,86708,HCPCS,Outpatient,,,156.15,93.69,,43.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,109.31,70,,,percent of total billed charges,70% of total billed charges,117.11,75,,,percent of total billed charges,75% of total billed charges,22.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.36,350,,,Fee Schedule,350% of CMS OPPS Rate,12.63,102,,,Fee Schedule,102% of CMS OPPS Rate,119.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,70.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.76,100,,,Fee Schedule,100% of UHC Fee Schedule,109.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,28.49,230,,,Fee Schedule,230% of CMS OPPS Rate,74.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,140.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.39,140.54,
COAGULATION AND FIBRINOLYSIS ACTIVITY,4085397,CDM,305,RC,85397,HCPCS,Outpatient,,,440,264,,109.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,30.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,308,70,,,percent of total billed charges,70% of total billed charges,330,75,,,percent of total billed charges,75% of total billed charges,55.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.01,350,,,Fee Schedule,350% of CMS OPPS Rate,31.47,102,,,Fee Schedule,102% of CMS OPPS Rate,336.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,198,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,27.77,100,,,Fee Schedule,100% of UHC Fee Schedule,308,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,70.97,230,,,Fee Schedule,230% of CMS OPPS Rate,211.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,396,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,100,,,Fee Schedule,100% of CMS OPPS Rate,27.77,396,
FIBRINOLYTIC FACTOR INHIBITORS,4085410,CDM,302,RC,85410,HCPCS,Outpatient,,,69.62,41.77,,27.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.71,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.73,70,,,percent of total billed charges,70% of total billed charges,52.22,75,,,percent of total billed charges,75% of total billed charges,13.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.98,350,,,Fee Schedule,350% of CMS OPPS Rate,7.86,102,,,Fee Schedule,102% of CMS OPPS Rate,53.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,31.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of UHC Fee Schedule,48.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,17.73,230,,,Fee Schedule,230% of CMS OPPS Rate,33.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,62.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7.71,62.66,
FIBRINOLYTIC FACTORS AND INHIB,4085420,CDM,302,RC,85420,HCPCS,Outpatient,,,280,168,,23.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,11.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.85,350,,,Fee Schedule,350% of CMS OPPS Rate,6.66,102,,,Fee Schedule,102% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of UHC Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,15.01,230,,,Fee Schedule,230% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.53,252,
"PHOSPHOLIPID NEUTRALIZATION, PLT",4085597,CDM,300,RC,85597,HCPCS,Outpatient,,,91.16,54.7,,63.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.81,70,,,percent of total billed charges,70% of total billed charges,68.37,75,,,percent of total billed charges,75% of total billed charges,32.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.93,350,,,Fee Schedule,350% of CMS OPPS Rate,18.33,102,,,Fee Schedule,102% of CMS OPPS Rate,69.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,41.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.97,100,,,Fee Schedule,100% of UHC Fee Schedule,63.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,41.35,230,,,Fee Schedule,230% of CMS OPPS Rate,43.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,82.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,16.35,82.04,
"PHOSPHOLIPID NEURTRALIZATION, HEXAGONAL",4085598,CDM,300,RC,85598,HCPCS,Outpatient,,,204,122.4,,63.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.43,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,142.8,70,,,percent of total billed charges,70% of total billed charges,153,75,,,percent of total billed charges,75% of total billed charges,32.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.93,350,,,Fee Schedule,350% of CMS OPPS Rate,18.33,102,,,Fee Schedule,102% of CMS OPPS Rate,156.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,91.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.97,100,,,Fee Schedule,100% of UHC Fee Schedule,142.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,41.35,230,,,Fee Schedule,230% of CMS OPPS Rate,97.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,183.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.43,183.6,
PROTHROMBIN TM MIXING STD,4085611,CDM,305,RC,85611,HCPCS,Outpatient,,,26.55,15.93,,13.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,18.59,70,,,percent of total billed charges,70% of total billed charges,19.91,75,,,percent of total billed charges,75% of total billed charges,7.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,350,,,Fee Schedule,350% of CMS OPPS Rate,4.01,102,,,Fee Schedule,102% of CMS OPPS Rate,20.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,11.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of UHC Fee Schedule,18.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,9.06,230,,,Fee Schedule,230% of CMS OPPS Rate,12.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,23.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,23.9,
"PTT SUBSTITUTION,PLASMA",4085732,CDM,300,RC,85732,HCPCS,Outpatient,,,27.45,16.47,,22.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.22,70,,,percent of total billed charges,70% of total billed charges,20.59,75,,,percent of total billed charges,75% of total billed charges,11.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.64,350,,,Fee Schedule,350% of CMS OPPS Rate,6.59,102,,,Fee Schedule,102% of CMS OPPS Rate,21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,7.18,100,,,Fee Schedule,100% of UHC Fee Schedule,19.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,230,,,Fee Schedule,230% of CMS OPPS Rate,13.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,24.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,100,,,Fee Schedule,100% of CMS OPPS Rate,6.47,24.71,
IGG SPECIFIC ALLERGINS,4086001,CDM,302,RC,86001,HCPCS,Outpatient,,,33.55,20.13,,27.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.49,70,,,percent of total billed charges,70% of total billed charges,25.16,75,,,percent of total billed charges,75% of total billed charges,14.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.37,350,,,Fee Schedule,350% of CMS OPPS Rate,7.97,102,,,Fee Schedule,102% of CMS OPPS Rate,25.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.04,100,,,Fee Schedule,100% of UHC Fee Schedule,23.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,230,,,Fee Schedule,230% of CMS OPPS Rate,16.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.04,30.2,
ALLERGEN SPECIFIC IGE PURIFIED EA,4086008,CDM,300,RC,86008,HCPCS,Outpatient,,,110.7,66.42,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.49,70,,,percent of total billed charges,70% of total billed charges,83.03,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,84.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,77.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,53.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,99.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,99.63,
ANTI-PLATELET ANTIBODY,4086014,CDM,302,RC,86022,HCPCS,Outpatient,,,94.5,56.7,,65.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,33.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.29,350,,,Fee Schedule,350% of CMS OPPS Rate,18.73,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,20.41,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,42.25,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,85.05,
SMOOTH MUSCLE AB (ASMA),4086015,CDM,300,RC,86015,HCPCS,Outpatient,,,58,34.8,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29,50,,,percent of total billed charges,pays at 50% of total billed charges,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,52.2,
"HEP DELTA VIRUS, TOTAL",4086018,CDM,302,RC,86692,HCPCS,Outpatient,,,124.85,74.91,,60.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.4,70,,,percent of total billed charges,70% of total billed charges,93.64,75,,,percent of total billed charges,75% of total billed charges,30.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.06,350,,,Fee Schedule,350% of CMS OPPS Rate,17.5,102,,,Fee Schedule,102% of CMS OPPS Rate,95.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,56.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,19.07,100,,,Fee Schedule,100% of UHC Fee Schedule,87.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.46,230,,,Fee Schedule,230% of CMS OPPS Rate,59.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,112.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,17.16,100,,,Fee Schedule,100% of CMS OPPS Rate,15.55,112.37,
ANCA SCREEN EA AB,4086036,CDM,300,RC,86036,HCPCS,Outpatient,,,110,66,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55,50,,,percent of total billed charges,pays at 50% of total billed charges,77,70,,,percent of total billed charges,70% of total billed charges,82.5,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,84.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,52.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,99,
ANCA TITER EA AB,4086037,CDM,300,RC,86037,HCPCS,Outpatient,,,62,37.2,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,55.8,
AQUAPORIN 4 AB CBA,4086052,CDM,300,RC,86052,HCPCS,Outpatient,,,936,561.6,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,468,50,,,percent of total billed charges,pays at 50% of total billed charges,655.2,70,,,percent of total billed charges,70% of total billed charges,702,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,748.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,716.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,421.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,655.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,561.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,468,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,655.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,449.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,842.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,842.4,
B CELL TOTAL COUNT,4086064,CDM,302,RC,86355,HCPCS,Outpatient,,,113,67.8,,133.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,67.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.05,350,,,Fee Schedule,350% of CMS OPPS Rate,38.48,102,,,Fee Schedule,102% of CMS OPPS Rate,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of UHC Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,230,,,Fee Schedule,230% of CMS OPPS Rate,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,133.56,
ANTI-DS DNA,4086102,CDM,302,RC,86225,HCPCS,Outpatient,,,47.3,28.38,,48.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges,35.48,75,,,percent of total billed charges,75% of total billed charges,24.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,350,,,Fee Schedule,350% of CMS OPPS Rate,14.01,102,,,Fee Schedule,102% of CMS OPPS Rate,36.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.27,100,,,Fee Schedule,100% of UHC Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,48.63,
BETA 2 GLYCOPROTEIN 1 AB,4086146,CDM,300,RC,86146,HCPCS,Outpatient,,,76,45.6,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.15,90.09,
TOXOPLASMA (TOXO AB),4086182,CDM,302,RC,86777,HCPCS,Outpatient,,,66.15,39.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.81,59.54,
"TOXOPLASMA, IGM ABS",4086184,CDM,302,RC,86778,HCPCS,Outpatient,,,66.15,39.69,,51.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.43,350,,,Fee Schedule,350% of CMS OPPS Rate,14.69,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,33.14,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,59.54,
PHOSPHATIDYL AB,4086198,CDM,302,RC,86148,HCPCS,Outpatient,,,48,28.8,,56.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.6,70,,,percent of total billed charges,70% of total billed charges,36,75,,,percent of total billed charges,75% of total billed charges,28.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.24,350,,,Fee Schedule,350% of CMS OPPS Rate,16.39,102,,,Fee Schedule,102% of CMS OPPS Rate,36.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of UHC Fee Schedule,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,36.96,230,,,Fee Schedule,230% of CMS OPPS Rate,23.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.65,56.88,
DNA ANTIBODY,4086215,CDM,302,RC,86215,HCPCS,Outpatient,,,130,78,,46.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,91,70,,,percent of total billed charges,70% of total billed charges,97.5,75,,,percent of total billed charges,75% of total billed charges,23.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.37,350,,,Fee Schedule,350% of CMS OPPS Rate,13.51,102,,,Fee Schedule,102% of CMS OPPS Rate,99.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,58.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of UHC Fee Schedule,91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.47,230,,,Fee Schedule,230% of CMS OPPS Rate,62.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,117,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.25,117,
DNA ANTIBODY SGL STRANDED,4086226,CDM,302,RC,86226,HCPCS,Outpatient,,,249,149.4,,42.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,21.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.38,350,,,Fee Schedule,350% of CMS OPPS Rate,12.35,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,13.46,100,,,Fee Schedule,100% of UHC Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,224.1,
ENDOMYSIAL AB IG,4086231,CDM,300,RC,86231,HCPCS,Outpatient,,,62,37.2,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31,50,,,percent of total billed charges,pays at 50% of total billed charges,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.07,55.8,
SM(SMITH) IGG ABS,4086235,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
FLORESCENT CHEM ABS,4086256,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
GLIADIN D PEPTIDED IG CLASS,4086258,CDM,300,RC,86258,HCPCS,Outpatient,,,58,34.8,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29,50,,,percent of total billed charges,pays at 50% of total billed charges,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,52.2,
HEPATITIS BE ANTIGEN,4086293,CDM,306,RC,87350,HCPCS,Outpatient,,,222.75,133.65,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.93,70,,,percent of total billed charges,70% of total billed charges,167.06,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,178.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,170.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,100.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.81,100,,,Fee Schedule,100% of UHC Fee Schedule,155.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,106.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,200.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,200.48,
HEPATITIS BE ANTIBODY,4086295,CDM,302,RC,86707,HCPCS,Outpatient,,,162.8,97.68,,40.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.96,70,,,percent of total billed charges,70% of total billed charges,122.1,75,,,percent of total billed charges,75% of total billed charges,20.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,130.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.49,350,,,Fee Schedule,350% of CMS OPPS Rate,11.8,102,,,Fee Schedule,102% of CMS OPPS Rate,124.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,73.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,100,,,Fee Schedule,100% of UHC Fee Schedule,113.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,230,,,Fee Schedule,230% of CMS OPPS Rate,78.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,146.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,146.52,
HIV-1 CONFIRM + BANDS,4086300,CDM,302,RC,86689,HCPCS,Outpatient,,,57.75,34.65,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges,43.31,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,44.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,25.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,27.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,68.49,
HUMAN EPIDIDYMIS PROTEIN 4,4086305,CDM,301,RC,86305,HCPCS,Outpatient,,,512,307.2,,73.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,358.4,70,,,percent of total billed charges,70% of total billed charges,384,75,,,percent of total billed charges,75% of total billed charges,37.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,409.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,350,,,Fee Schedule,350% of CMS OPPS Rate,21.22,102,,,Fee Schedule,102% of CMS OPPS Rate,391.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,358.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,307.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of UHC Fee Schedule,358.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.86,230,,,Fee Schedule,230% of CMS OPPS Rate,245.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,460.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,460.8,
IMMUNOASSAY/TUMOR AG,4086316,CDM,302,RC,86316,HCPCS,Outpatient,,,62,37.2,,73.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,37.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.83,350,,,Fee Schedule,350% of CMS OPPS Rate,21.22,102,,,Fee Schedule,102% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,23.13,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,47.86,230,,,Fee Schedule,230% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,100,,,Fee Schedule,100% of CMS OPPS Rate,20.81,73.66,
"IMMUNOASSAY, INFECTIOUS A",4086317,CDM,302,RC,86317,HCPCS,Outpatient,,,93.6,56.16,,53.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.52,70,,,percent of total billed charges,70% of total billed charges,70.2,75,,,percent of total billed charges,75% of total billed charges,26.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.46,350,,,Fee Schedule,350% of CMS OPPS Rate,15.28,102,,,Fee Schedule,102% of CMS OPPS Rate,71.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,42.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,16.65,100,,,Fee Schedule,100% of UHC Fee Schedule,65.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,34.47,230,,,Fee Schedule,230% of CMS OPPS Rate,44.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,100,,,Fee Schedule,100% of CMS OPPS Rate,14.99,84.24,
IMMUNOELECTROPHORESIS SERUM,4086320,CDM,302,RC,86320,HCPCS,Outpatient,,,202.24,121.34,,105.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,141.57,70,,,percent of total billed charges,70% of total billed charges,151.68,75,,,percent of total billed charges,75% of total billed charges,53.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,161.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104.72,350,,,Fee Schedule,350% of CMS OPPS Rate,30.51,102,,,Fee Schedule,102% of CMS OPPS Rate,154.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,91.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.93,100,,,Fee Schedule,100% of UHC Fee Schedule,141.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,68.81,230,,,Fee Schedule,230% of CMS OPPS Rate,97.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,182.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,182.02,
IMMUNFIX E-PHORSIS/URINE,4086335,CDM,302,RC,86335,HCPCS,Outpatient,,,94.5,56.7,,103.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,52.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.72,350,,,Fee Schedule,350% of CMS OPPS Rate,29.93,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,67.5,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,29.35,100,,,Fee Schedule,100% of CMS OPPS Rate,14.81,103.89,
Blood test to monitor for cancer in the ovaries or testis,4086336,CDM,302,RC,86336,HCPCS,Outpatient,,,76.5,45.9,,55.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.55,70,,,percent of total billed charges,70% of total billed charges,57.38,75,,,percent of total billed charges,75% of total billed charges,28.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.56,350,,,Fee Schedule,350% of CMS OPPS Rate,15.9,102,,,Fee Schedule,102% of CMS OPPS Rate,58.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,17.32,100,,,Fee Schedule,100% of UHC Fee Schedule,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,35.85,230,,,Fee Schedule,230% of CMS OPPS Rate,36.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,68.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,68.85,
INSULIN ANTIBODIES,4086337,CDM,300,RC,86337,HCPCS,Outpatient,,,67,40.2,,75.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,38.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.93,350,,,Fee Schedule,350% of CMS OPPS Rate,21.83,102,,,Fee Schedule,102% of CMS OPPS Rate,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,23.79,100,,,Fee Schedule,100% of UHC Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,49.24,230,,,Fee Schedule,230% of CMS OPPS Rate,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,9.87,75.79,
LHR TEST,4086343,CDM,302,RC,86343,HCPCS,Outpatient,,,139.5,83.7,,44.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.65,70,,,percent of total billed charges,70% of total billed charges,104.63,75,,,percent of total billed charges,75% of total billed charges,22.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,43.61,350,,,Fee Schedule,350% of CMS OPPS Rate,12.7,102,,,Fee Schedule,102% of CMS OPPS Rate,106.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,13.84,100,,,Fee Schedule,100% of UHC Fee Schedule,97.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,28.65,230,,,Fee Schedule,230% of CMS OPPS Rate,66.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,125.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,100,,,Fee Schedule,100% of CMS OPPS Rate,12.46,125.55,
CELL FUNCTION ASSAY W/STIM,4086352,CDM,302,RC,86352,HCPCS,Outpatient,,,270,162,,480.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,89.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,135.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,135.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,341.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,189,70,,,percent of total billed charges,70% of total billed charges,202.5,75,,,percent of total billed charges,75% of total billed charges,244.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,475.51,350,,,Fee Schedule,350% of CMS OPPS Rate,138.57,102,,,Fee Schedule,102% of CMS OPPS Rate,206.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,121.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,150.96,100,,,Fee Schedule,100% of UHC Fee Schedule,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,270,230,,,Fee Schedule,230% of CMS OPPS Rate,129.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,243,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,89.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,89.62,480.94,
NATURAL KILLER CELLS TOTAL CNT,4086357,CDM,302,RC,86357,HCPCS,Outpatient,,,134,80.4,,133.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges,100.5,75,,,percent of total billed charges,75% of total billed charges,67.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.05,350,,,Fee Schedule,350% of CMS OPPS Rate,38.48,102,,,Fee Schedule,102% of CMS OPPS Rate,102.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of UHC Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,230,,,Fee Schedule,230% of CMS OPPS Rate,64.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,120.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,133.56,
CD4  ABSOLUTE COUNT,4086361,CDM,300,RC,86361,HCPCS,Outpatient,,,142.2,85.32,,94.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.54,70,,,percent of total billed charges,70% of total billed charges,106.65,75,,,percent of total billed charges,75% of total billed charges,48.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,113.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.73,350,,,Fee Schedule,350% of CMS OPPS Rate,27.31,102,,,Fee Schedule,102% of CMS OPPS Rate,108.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,63.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,29.75,100,,,Fee Schedule,100% of UHC Fee Schedule,99.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,61.59,230,,,Fee Schedule,230% of CMS OPPS Rate,68.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,127.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,127.98,
MYELIN O. GLYCOPROTEIN CBA,4086362,CDM,300,RC,86362,HCPCS,Outpatient,,,1100,660,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,550,50,,,percent of total billed charges,pays at 50% of total billed charges,770,70,,,percent of total billed charges,70% of total billed charges,825,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,841.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,495,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,770,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,660,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,770,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,528,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,990,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,9.04,990,
TISSUE TRANSGLUTAMINASE IG,4086364,CDM,300,RC,86364,HCPCS,Outpatient,,,106,63.6,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53,50,,,percent of total billed charges,pays at 50% of total billed charges,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,81.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,95.4,
MITOCHONDRIAL AB EG,4086381,CDM,300,RC,86381,HCPCS,Outpatient,,,128,76.8,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64,50,,,percent of total billed charges,pays at 50% of total billed charges,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,115.2,
"NEUTRALIZATION TEST, VIRAL",4086382,CDM,302,RC,86382,HCPCS,Outpatient,,,316,189.6,,59.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221.2,70,,,percent of total billed charges,70% of total billed charges,237,75,,,percent of total billed charges,75% of total billed charges,30.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,252.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.18,350,,,Fee Schedule,350% of CMS OPPS Rate,17.24,102,,,Fee Schedule,102% of CMS OPPS Rate,241.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,142.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,18.79,100,,,Fee Schedule,100% of UHC Fee Schedule,221.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,38.89,230,,,Fee Schedule,230% of CMS OPPS Rate,151.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,284.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.91,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,284.4,
PA SCREEN EA AB,4086403,CDM,302,RC,86403,HCPCS,Outpatient,,,74.7,44.82,,40.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges,56.03,75,,,percent of total billed charges,75% of total billed charges,20.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.38,350,,,Fee Schedule,350% of CMS OPPS Rate,11.77,102,,,Fee Schedule,102% of CMS OPPS Rate,57.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,33.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.32,100,,,Fee Schedule,100% of UHC Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,26.54,230,,,Fee Schedule,230% of CMS OPPS Rate,35.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.32,67.23,
PA TITER EA AB,4086406,CDM,302,RC,86406,HCPCS,Outpatient,,,74.7,44.82,,37.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges,56.03,75,,,percent of total billed charges,75% of total billed charges,19.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.24,350,,,Fee Schedule,350% of CMS OPPS Rate,10.85,102,,,Fee Schedule,102% of CMS OPPS Rate,57.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,33.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,11.82,100,,,Fee Schedule,100% of UHC Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,24.47,230,,,Fee Schedule,230% of CMS OPPS Rate,35.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,100,,,Fee Schedule,100% of CMS OPPS Rate,10.64,67.23,
"TB TEST,CELL IMMUN MEASUR",4086480,CDM,302,RC,86480,HCPCS,Outpatient,,,186,111.6,,219.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,61.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,156.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,111.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,216.93,350,,,Fee Schedule,350% of CMS OPPS Rate,63.21,102,,,Fee Schedule,102% of CMS OPPS Rate,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,68.87,100,,,Fee Schedule,100% of UHC Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,142.55,230,,,Fee Schedule,230% of CMS OPPS Rate,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,100,,,Fee Schedule,100% of CMS OPPS Rate,61.98,219.4,
TB AG RESPONSE T-CELL SUSP,4086481,CDM,302,RC,86481,HCPCS,Outpatient,,,300,180,,354,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,80.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,100,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,100,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,203.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,180,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,350,350,,,Fee Schedule,350% of CMS OPPS Rate,102,102,,,Fee Schedule,102% of CMS OPPS Rate,229.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,100,100,,,Fee Schedule,100% of CMS OPPS Rate,90,100,,,Fee Schedule,100% of UHC Fee Schedule,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100,100,,,Fee Schedule,100% of CMS OPPS Rate,230,230,,,Fee Schedule,230% of CMS OPPS Rate,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,Fee Schedule,100% of CMS OPPS Rate,270,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,80.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,100,100,,,Fee Schedule,100% of CMS OPPS Rate,80.56,354,
"TISSUE CULT (CHRM), BM",4086510,CDM,311,RC,88237,HCPCS,Outpatient,,,431,258.6,,508.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,143.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,143.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,317.93,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,301.7,70,,,percent of total billed charges,70% of total billed charges,323.25,75,,,percent of total billed charges,75% of total billed charges,258.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,344.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,503.12,350,,,Fee Schedule,350% of CMS OPPS Rate,146.62,102,,,Fee Schedule,102% of CMS OPPS Rate,329.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,193.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,140.34,100,,,Fee Schedule,100% of UHC Fee Schedule,301.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,330.62,230,,,Fee Schedule,230% of CMS OPPS Rate,206.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,387.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,100,,,Fee Schedule,100% of CMS OPPS Rate,77.9,508.87,
"TISSUE CULT (CHROM), BLD",4086514,CDM,311,RC,88230,HCPCS,Outpatient,,,275,165,,412.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,116.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,293.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,209.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,407.71,350,,,Fee Schedule,350% of CMS OPPS Rate,118.81,102,,,Fee Schedule,102% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,129.44,100,,,Fee Schedule,100% of UHC Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,267.92,230,,,Fee Schedule,230% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,77.9,412.37,
"TISSUE CULT (CHRM),TISSUE",4086520,CDM,311,RC,88233,HCPCS,Outpatient,,,479.25,287.55,,498.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,140.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,140.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,354.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,335.48,70,,,percent of total billed charges,70% of total billed charges,359.44,75,,,percent of total billed charges,75% of total billed charges,253.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,383.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492.55,350,,,Fee Schedule,350% of CMS OPPS Rate,143.54,102,,,Fee Schedule,102% of CMS OPPS Rate,366.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,215.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,156.37,100,,,Fee Schedule,100% of UHC Fee Schedule,335.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,323.67,230,,,Fee Schedule,230% of CMS OPPS Rate,230.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,431.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,77.9,498.18,
"BACTERIUM ABS,IMMUNOASSAY",4086609,CDM,300,RC,86609,HCPCS,Outpatient,,,39,23.4,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,45.59,
BORDETELLA P. ABS,4086615,CDM,302,RC,86615,HCPCS,Outpatient,,,40.7,24.42,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
CAMPYLOBACTER ABS,4086625,CDM,300,RC,86625,HCPCS,Outpatient,,,63.45,38.07,,46.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,23.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.92,350,,,Fee Schedule,350% of CMS OPPS Rate,13.38,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.58,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.12,57.11,
ANTIBODY COCCIDIOIDES,4086635,CDM,302,RC,86635,HCPCS,Outpatient,,,41,24.6,,40.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.14,350,,,Fee Schedule,350% of CMS OPPS Rate,11.69,102,,,Fee Schedule,102% of CMS OPPS Rate,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.75,100,,,Fee Schedule,100% of UHC Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,230,,,Fee Schedule,230% of CMS OPPS Rate,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,100,,,Fee Schedule,100% of CMS OPPS Rate,11.47,40.6,
ANTIBODY COXIELLA BURNETI,4086638,CDM,302,RC,86638,HCPCS,Outpatient,,,80,48,,42.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,21.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.42,350,,,Fee Schedule,350% of CMS OPPS Rate,12.36,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.47,100,,,Fee Schedule,100% of UHC Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,27.87,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,72,
CALIF LA CROSSE VIRUS ENC,4086651,CDM,302,RC,86651,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
EASTERN EQUINE ENCEPH ABS,4086652,CDM,302,RC,86652,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
ST LOUIS ENCEPH. ABS,4086653,CDM,302,RC,86653,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
WESTERN EQUINE ENCEPH ABS,4086654,CDM,302,RC,86654,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
EHRLICHIA ABS,4086666,CDM,300,RC,86666,HCPCS,Outpatient,,,31.95,19.17,,36.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,18.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.63,350,,,Fee Schedule,350% of CMS OPPS Rate,10.38,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,23.41,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,36.03,
"STRONGYLOIDES, IGG ABS",4086682,CDM,302,RC,86682,HCPCS,Outpatient,,,108.9,65.34,,46.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.23,70,,,percent of total billed charges,70% of total billed charges,81.68,75,,,percent of total billed charges,75% of total billed charges,23.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,87.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.53,350,,,Fee Schedule,350% of CMS OPPS Rate,13.27,102,,,Fee Schedule,102% of CMS OPPS Rate,83.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of UHC Fee Schedule,76.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,29.92,230,,,Fee Schedule,230% of CMS OPPS Rate,52.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,98.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,98.01,
HAEMOPHILUS INF. B ABS,4086684,CDM,302,RC,86684,HCPCS,Outpatient,,,189.9,113.94,,56.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,132.93,70,,,percent of total billed charges,70% of total billed charges,142.43,75,,,percent of total billed charges,75% of total billed charges,28.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,151.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.44,350,,,Fee Schedule,350% of CMS OPPS Rate,16.15,102,,,Fee Schedule,102% of CMS OPPS Rate,145.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,85.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17.6,100,,,Fee Schedule,100% of UHC Fee Schedule,132.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,36.43,230,,,Fee Schedule,230% of CMS OPPS Rate,91.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,170.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.84,170.91,
HTLV I ANTIBODY,4086687,CDM,302,RC,86687,HCPCS,Outpatient,,,75.82,45.49,,32.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.07,70,,,percent of total billed charges,70% of total billed charges,56.87,75,,,percent of total billed charges,75% of total billed charges,16.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.81,350,,,Fee Schedule,350% of CMS OPPS Rate,9.27,102,,,Fee Schedule,102% of CMS OPPS Rate,58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,34.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.32,100,,,Fee Schedule,100% of UHC Fee Schedule,53.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,20.9,230,,,Fee Schedule,230% of CMS OPPS Rate,36.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,68.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,100,,,Fee Schedule,100% of CMS OPPS Rate,9.09,68.24,
HTLV II ANTIBODY,4086688,CDM,302,RC,86688,HCPCS,Outpatient,,,95.26,57.16,,49.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.68,70,,,percent of total billed charges,70% of total billed charges,71.45,75,,,percent of total billed charges,75% of total billed charges,25.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49,350,,,Fee Schedule,350% of CMS OPPS Rate,14.28,102,,,Fee Schedule,102% of CMS OPPS Rate,72.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,42.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14,100,,,Fee Schedule,100% of CMS OPPS Rate,15.56,100,,,Fee Schedule,100% of UHC Fee Schedule,66.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14,100,,,Fee Schedule,100% of CMS OPPS Rate,32.2,230,,,Fee Schedule,230% of CMS OPPS Rate,45.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14,100,,,Fee Schedule,100% of CMS OPPS Rate,85.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,14,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,85.73,
HIV 2 IGG ABS (REFLEX),4086702,CDM,302,RC,86702,HCPCS,Outpatient,,,52.5,31.5,,47.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.75,70,,,percent of total billed charges,70% of total billed charges,39.38,75,,,percent of total billed charges,75% of total billed charges,24.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.32,350,,,Fee Schedule,350% of CMS OPPS Rate,13.79,102,,,Fee Schedule,102% of CMS OPPS Rate,40.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15.02,100,,,Fee Schedule,100% of UHC Fee Schedule,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,31.09,230,,,Fee Schedule,230% of CMS OPPS Rate,25.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,47.86,
Blood test to diagnose HIV,4086703,CDM,302,RC,86703,HCPCS,Outpatient,,,169.2,101.52,,48.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.44,70,,,percent of total billed charges,70% of total billed charges,126.9,75,,,percent of total billed charges,75% of total billed charges,24.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.98,350,,,Fee Schedule,350% of CMS OPPS Rate,13.98,102,,,Fee Schedule,102% of CMS OPPS Rate,129.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,76.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15.23,100,,,Fee Schedule,100% of UHC Fee Schedule,118.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,31.53,230,,,Fee Schedule,230% of CMS OPPS Rate,81.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,152.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13.71,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,152.28,
ANTIBODY JC VIRUS,4086711,CDM,302,RC,86711,HCPCS,Outpatient,,,1363,817.8,,59.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.89,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,954.1,70,,,percent of total billed charges,70% of total billed charges,1022.25,75,,,percent of total billed charges,75% of total billed charges,30.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1090.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.11,350,,,Fee Schedule,350% of CMS OPPS Rate,17.22,102,,,Fee Schedule,102% of CMS OPPS Rate,1042.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,613.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,954.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,817.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,954.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,38.84,230,,,Fee Schedule,230% of CMS OPPS Rate,654.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,1226.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,16.89,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,1226.7,
LISTERIA AB MONOCYTOGENES,4086723,CDM,302,RC,86723,HCPCS,Outpatient,,,144,86.4,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,129.6,
ANTIBODY LYMPH CHORIOMENINGTIS,4086727,CDM,302,RC,86727,HCPCS,Outpatient,,,46,27.6,,45.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.12,102,,,Fee Schedule,102% of CMS OPPS Rate,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,29.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,45.55,
SAR COVID-19 ANTIBODY,4086769,CDM,300,RC,86769,HCPCS,Outpatient,,,144,86.4,,149.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72,50,,,percent of total billed charges,pays at 50% of total billed charges,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,75.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.45,350,,,Fee Schedule,350% of CMS OPPS Rate,42.97,102,,,Fee Schedule,102% of CMS OPPS Rate,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,96.89,230,,,Fee Schedule,230% of CMS OPPS Rate,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,149.14,
"WEST NILE VIRUS AB, IGM",4086788,CDM,302,RC,86788,HCPCS,Outpatient,,,60,36,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,100,,,Fee Schedule,100% of UHC Fee Schedule,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,59.64,
WEST NILE VIRUS ANTIBODY,4086789,CDM,302,RC,86789,HCPCS,Outpatient,,,43,25.8,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,50.94,
WEST NILE VIRUS ABS,4086790,CDM,302,RC,86790,HCPCS,Outpatient,,,204.3,122.58,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.01,70,,,percent of total billed charges,70% of total billed charges,153.23,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,163.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,156.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,143.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,98.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,183.87,
Blood test to determine infection with Hepatitis C,4086804,CDM,302,RC,86803,HCPCS,Outpatient,,,188.1,112.86,,50.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges,141.08,75,,,percent of total billed charges,75% of total billed charges,25.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,150.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.94,350,,,Fee Schedule,350% of CMS OPPS Rate,14.55,102,,,Fee Schedule,102% of CMS OPPS Rate,143.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,84.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.85,100,,,Fee Schedule,100% of UHC Fee Schedule,131.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,32.82,230,,,Fee Schedule,230% of CMS OPPS Rate,90.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,169.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,169.29,
ALPHA FETOPROTEIN TUMOR M,4087000,CDM,301,RC,82105,HCPCS,Outpatient,,,105.05,63.03,,59.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.54,70,,,percent of total billed charges,70% of total billed charges,78.79,75,,,percent of total billed charges,75% of total billed charges,30.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.69,350,,,Fee Schedule,350% of CMS OPPS Rate,17.1,102,,,Fee Schedule,102% of CMS OPPS Rate,80.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,47.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,18.64,100,,,Fee Schedule,100% of UHC Fee Schedule,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,230,,,Fee Schedule,230% of CMS OPPS Rate,50.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.77,100,,,Fee Schedule,100% of CMS OPPS Rate,16.69,94.55,
Blood test to monitor for cancer in the ovaries or testis,4087000,CDM,302,RC,86336,HCPCS,Outpatient,,,76.5,45.9,,55.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.55,70,,,percent of total billed charges,70% of total billed charges,57.38,75,,,percent of total billed charges,75% of total billed charges,28.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.56,350,,,Fee Schedule,350% of CMS OPPS Rate,15.9,102,,,Fee Schedule,102% of CMS OPPS Rate,58.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,17.32,100,,,Fee Schedule,100% of UHC Fee Schedule,53.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,35.85,230,,,Fee Schedule,230% of CMS OPPS Rate,36.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,68.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,100,,,Fee Schedule,100% of CMS OPPS Rate,15.59,68.85,
HCG QUANTITATIVE SERUM,4087000,CDM,301,RC,84702,HCPCS,Outpatient,,,457.6,274.56,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,320.32,70,,,percent of total billed charges,70% of total billed charges,343.2,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,366.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,350.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,320.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,274.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,320.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,219.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,411.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,411.84,
ESTRIOL(ALPHA FETOPROTEIN,4087000,CDM,301,RC,82677,HCPCS,Outpatient,,,73,43.8,,85.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.1,70,,,percent of total billed charges,70% of total billed charges,54.75,75,,,percent of total billed charges,75% of total billed charges,43.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.63,350,,,Fee Schedule,350% of CMS OPPS Rate,24.66,102,,,Fee Schedule,102% of CMS OPPS Rate,55.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,32.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,26.87,100,,,Fee Schedule,100% of UHC Fee Schedule,51.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,55.61,230,,,Fee Schedule,230% of CMS OPPS Rate,35.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,65.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,85.59,
ANTI-VARICELLA  EIA,4087002,CDM,302,RC,86787,HCPCS,Outpatient,,,105.05,63.03,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.54,70,,,percent of total billed charges,70% of total billed charges,78.79,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,80.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,47.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,73.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,50.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,94.55,
IGE SPECIFIC ALLERGINS,4087007,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE-IMMUNOGLOBULIN E,4087007,CDM,301,RC,82785,HCPCS,Outpatient,,,57.75,34.65,,58.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges,43.31,75,,,percent of total billed charges,75% of total billed charges,29.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.61,350,,,Fee Schedule,350% of CMS OPPS Rate,16.78,102,,,Fee Schedule,102% of CMS OPPS Rate,44.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,18.29,100,,,Fee Schedule,100% of UHC Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,37.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,58.26,
BARTONELLA ABS,4087008,CDM,302,RC,86611,HCPCS,Outpatient,,,96.3,57.78,,36.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,67.41,70,,,percent of total billed charges,70% of total billed charges,72.23,75,,,percent of total billed charges,75% of total billed charges,18.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.63,350,,,Fee Schedule,350% of CMS OPPS Rate,10.38,102,,,Fee Schedule,102% of CMS OPPS Rate,73.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of UHC Fee Schedule,67.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,23.41,230,,,Fee Schedule,230% of CMS OPPS Rate,46.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,86.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,86.67,
ARSENIC (HEAVY METAL),4087100,CDM,301,RC,82175,HCPCS,Outpatient,,,106.15,63.69,,67.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,34.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.39,350,,,Fee Schedule,350% of CMS OPPS Rate,19.34,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,21.08,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,43.63,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,95.54,
MICROSOMAL AB,4087103,CDM,302,RC,86376,HCPCS,Outpatient,,,95.7,57.42,,51.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,26.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.92,350,,,Fee Schedule,350% of CMS OPPS Rate,14.84,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,86.13,
ANTI-DS DNA,4087103,CDM,302,RC,86225,HCPCS,Outpatient,,,47.3,28.38,,48.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges,35.48,75,,,percent of total billed charges,75% of total billed charges,24.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,350,,,Fee Schedule,350% of CMS OPPS Rate,14.01,102,,,Fee Schedule,102% of CMS OPPS Rate,36.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.27,100,,,Fee Schedule,100% of UHC Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,48.63,
COMPLEMENT AG,4087103,CDM,302,RC,86160,HCPCS,Outpatient,,,44,26.4,,42.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,21.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,350,,,Fee Schedule,350% of CMS OPPS Rate,12.24,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,100% of UHC Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,27.6,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,42.48,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4087103,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
SM(SMITH) IGG ABS,4087103,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
ANA(REFLEX TITER),4087103,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
RA QUANTITATIVE,4087103,CDM,302,RC,86431,HCPCS,Outpatient,,,88,52.8,,20.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,10.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.84,350,,,Fee Schedule,350% of CMS OPPS Rate,5.78,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.04,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,79.2,
MICROSOMAL AB,4087104,CDM,302,RC,86376,HCPCS,Outpatient,,,95.7,57.42,,51.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,26.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.92,350,,,Fee Schedule,350% of CMS OPPS Rate,14.84,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,86.13,
ANTI-DS DNA,4087104,CDM,302,RC,86225,HCPCS,Outpatient,,,47.3,28.38,,48.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges,35.48,75,,,percent of total billed charges,75% of total billed charges,24.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,350,,,Fee Schedule,350% of CMS OPPS Rate,14.01,102,,,Fee Schedule,102% of CMS OPPS Rate,36.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.27,100,,,Fee Schedule,100% of UHC Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,48.63,
COMPLEMENT AG,4087104,CDM,302,RC,86160,HCPCS,Outpatient,,,44,26.4,,42.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,21.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42,350,,,Fee Schedule,350% of CMS OPPS Rate,12.24,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,13.33,100,,,Fee Schedule,100% of UHC Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,27.6,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,100,,,Fee Schedule,100% of CMS OPPS Rate,12,42.48,
IMMUNOASSAY ANALYTE,4087104,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
RA QUANTITATIVE,4087104,CDM,302,RC,86431,HCPCS,Outpatient,,,88,52.8,,20.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,10.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.84,350,,,Fee Schedule,350% of CMS OPPS Rate,5.78,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.04,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,79.2,
EXTRACTABLE N AG IGG ABS,4087104,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
Blood test to determine cause of inappropriate blood clot formation,4087106,CDM,302,RC,86147,HCPCS,Outpatient,,,139.7,83.82,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges,104.78,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,106.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,62.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,67.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,125.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,125.73,
LUPUS ANTICOAGULANT,4087106,CDM,305,RC,85613,HCPCS,Outpatient,,,68.2,40.92,,33.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges,51.15,75,,,percent of total billed charges,75% of total billed charges,17.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.53,350,,,Fee Schedule,350% of CMS OPPS Rate,9.77,102,,,Fee Schedule,102% of CMS OPPS Rate,52.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,30.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,10.65,100,,,Fee Schedule,100% of UHC Fee Schedule,47.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,22.03,230,,,Fee Schedule,230% of CMS OPPS Rate,32.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9.58,61.38,
BETA 2 GLYCOPROTEIN 1 AB,4087106,CDM,300,RC,86146,HCPCS,Outpatient,,,76,45.6,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.15,90.09,
PHOSPHATIDYL AB,4087106,CDM,302,RC,86148,HCPCS,Outpatient,,,48,28.8,,56.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.6,70,,,percent of total billed charges,70% of total billed charges,36,75,,,percent of total billed charges,75% of total billed charges,28.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.24,350,,,Fee Schedule,350% of CMS OPPS Rate,16.39,102,,,Fee Schedule,102% of CMS OPPS Rate,36.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,21.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of UHC Fee Schedule,33.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,36.96,230,,,Fee Schedule,230% of CMS OPPS Rate,23.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.65,56.88,
ASPERGILLUS ABS,4087107,CDM,302,RC,86606,HCPCS,Outpatient,,,50.6,30.36,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
ANTITHROMBIN III,4087108,CDM,305,RC,85301,HCPCS,Outpatient,,,152.1,91.26,,38.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,19.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.83,350,,,Fee Schedule,350% of CMS OPPS Rate,11.02,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,24.86,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,100,,,Fee Schedule,100% of CMS OPPS Rate,10.81,136.89,
CLOTTING INHIBITORS,4087108,CDM,305,RC,85300,HCPCS,Outpatient,,,36,21.6,,41.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges,27,75,,,percent of total billed charges,75% of total billed charges,21.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.47,350,,,Fee Schedule,350% of CMS OPPS Rate,12.08,102,,,Fee Schedule,102% of CMS OPPS Rate,27.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,13.17,100,,,Fee Schedule,100% of UHC Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.25,230,,,Fee Schedule,230% of CMS OPPS Rate,17.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,100,,,Fee Schedule,100% of CMS OPPS Rate,11.85,41.94,
ANTIBODY ID LEUKOCYTE ABS,4087109,CDM,302,RC,86021,HCPCS,Outpatient,,,54.45,32.67,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
ANA(REFLEX TITER),4087109,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
MERCURY QUANTITATIVE,4087110,CDM,301,RC,83825,HCPCS,Outpatient,,,106.15,63.69,,57.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,29.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.91,350,,,Fee Schedule,350% of CMS OPPS Rate,16.58,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,18.06,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.39,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,95.54,
BETA 2 GLYCOPROTEIN 1 AB,4087111,CDM,300,RC,86146,HCPCS,Outpatient,,,76,45.6,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16.15,90.09,
"TISSUE CULT (CHRM),TISSUE",4087126,CDM,311,RC,88233,HCPCS,Outpatient,,,479.25,287.55,,498.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,140.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,140.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,354.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,335.48,70,,,percent of total billed charges,70% of total billed charges,359.44,75,,,percent of total billed charges,75% of total billed charges,253.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,383.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,492.55,350,,,Fee Schedule,350% of CMS OPPS Rate,143.54,102,,,Fee Schedule,102% of CMS OPPS Rate,366.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,215.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,156.37,100,,,Fee Schedule,100% of UHC Fee Schedule,335.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,323.67,230,,,Fee Schedule,230% of CMS OPPS Rate,230.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,431.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,140.72,100,,,Fee Schedule,100% of CMS OPPS Rate,77.9,498.18,
CHROM ANALY 15 - 20 CELLS,4087126,CDM,311,RC,88262,HCPCS,Outpatient,,,423.45,254.07,,444.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,125.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,313.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,296.42,70,,,percent of total billed charges,70% of total billed charges,317.59,75,,,percent of total billed charges,75% of total billed charges,225.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,338.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,439.21,350,,,Fee Schedule,350% of CMS OPPS Rate,127.99,102,,,Fee Schedule,102% of CMS OPPS Rate,323.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of UHC Fee Schedule,296.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,288.62,230,,,Fee Schedule,230% of CMS OPPS Rate,203.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,381.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,444.23,
"TISSUE CULT (CHROM), BLD",4087128,CDM,311,RC,88230,HCPCS,Outpatient,,,275,165,,412.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,116.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,293.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,209.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,407.71,350,,,Fee Schedule,350% of CMS OPPS Rate,118.81,102,,,Fee Schedule,102% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,129.44,100,,,Fee Schedule,100% of UHC Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,267.92,230,,,Fee Schedule,230% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,116.49,100,,,Fee Schedule,100% of CMS OPPS Rate,77.9,412.37,
CHROM ANALY 15 - 20 CELLS,4087128,CDM,311,RC,88262,HCPCS,Outpatient,,,423.45,254.07,,444.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,125.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,313.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,296.42,70,,,percent of total billed charges,70% of total billed charges,317.59,75,,,percent of total billed charges,75% of total billed charges,225.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,338.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,439.21,350,,,Fee Schedule,350% of CMS OPPS Rate,127.99,102,,,Fee Schedule,102% of CMS OPPS Rate,323.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of UHC Fee Schedule,296.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,288.62,230,,,Fee Schedule,230% of CMS OPPS Rate,203.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,381.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,100,,,Fee Schedule,100% of CMS OPPS Rate,125.49,444.23,
Blood test to monitor for cytomegalovirus,4087129,CDM,302,RC,86644,HCPCS,Outpatient,,,106.15,63.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,95.54,
"ANTI-CMV AB,IGM",4087129,CDM,302,RC,86645,HCPCS,Outpatient,,,106.15,63.69,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,95.54,
COXSACKIE ENTEROVIRUS EA,4087130,CDM,302,RC,86658,HCPCS,Outpatient,,,74.5,44.7,,46.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.15,70,,,percent of total billed charges,70% of total billed charges,55.88,75,,,percent of total billed charges,75% of total billed charges,23.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.29,102,,,Fee Schedule,102% of CMS OPPS Rate,56.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,33.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.47,100,,,Fee Schedule,100% of UHC Fee Schedule,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,29.96,230,,,Fee Schedule,230% of CMS OPPS Rate,35.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,67.05,
Blood test to determine cause of inappropriate blood clot formation,4087131,CDM,302,RC,86147,HCPCS,Outpatient,,,139.7,83.82,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges,104.78,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,106.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,62.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,67.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,125.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,125.73,
Blood test for an STD,4087132,CDM,306,RC,87591,HCPCS,Outpatient,,,185.4,111.24,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges,139.05,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,141.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,88.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,166.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,166.86,
Test that detects Chlamydia,4087132,CDM,300,RC,87491,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
Blood test to diagnose mononucleosis,4087134,CDM,302,RC,86665,HCPCS,Outpatient,,,158.4,95.04,,64.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges,118.8,75,,,percent of total billed charges,75% of total billed charges,32.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.49,350,,,Fee Schedule,350% of CMS OPPS Rate,18.5,102,,,Fee Schedule,102% of CMS OPPS Rate,121.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of UHC Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,41.72,230,,,Fee Schedule,230% of CMS OPPS Rate,76.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,100,,,Fee Schedule,100% of CMS OPPS Rate,18.14,142.56,
EBV ANTIGEN,4087134,CDM,302,RC,86664,HCPCS,Outpatient,,,158.4,95.04,,54.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges,118.8,75,,,percent of total billed charges,75% of total billed charges,27.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.51,350,,,Fee Schedule,350% of CMS OPPS Rate,15.59,102,,,Fee Schedule,102% of CMS OPPS Rate,121.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,71.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,110.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,35.16,230,,,Fee Schedule,230% of CMS OPPS Rate,76.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,142.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,15.29,142.56,
COXSACKIE ENTEROVIRUS EA,4087135,CDM,302,RC,86658,HCPCS,Outpatient,,,74.5,44.7,,46.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.15,70,,,percent of total billed charges,70% of total billed charges,55.88,75,,,percent of total billed charges,75% of total billed charges,23.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.29,102,,,Fee Schedule,102% of CMS OPPS Rate,56.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,33.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.47,100,,,Fee Schedule,100% of UHC Fee Schedule,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,29.96,230,,,Fee Schedule,230% of CMS OPPS Rate,35.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,67.05,
EXTRACTABLE N AG IGG ABS,4087136,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
IMMUNOASSAY ANALYTE,4087139,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
HERPES SIM.VIRUS 1 ABS,4087140,CDM,302,RC,86695,HCPCS,Outpatient,,,45.1,27.06,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
HERPES SIMPLEX 2 ABS,4087140,CDM,302,RC,86696,HCPCS,Outpatient,,,240.35,144.21,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges,180.26,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,183.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,108.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,115.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,216.32,
ANTI-HISTOPLASMA ANTIBODY,4087143,CDM,302,RC,86698,HCPCS,Outpatient,,,97.2,58.32,,48.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.79,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.04,70,,,percent of total billed charges,70% of total billed charges,72.9,75,,,percent of total billed charges,75% of total billed charges,24.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.26,350,,,Fee Schedule,350% of CMS OPPS Rate,14.06,102,,,Fee Schedule,102% of CMS OPPS Rate,74.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,43.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.89,100,,,Fee Schedule,100% of UHC Fee Schedule,68.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,31.71,230,,,Fee Schedule,230% of CMS OPPS Rate,46.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,87.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,87.48,
CD4  ABSOLUTE COUNT,4087144,CDM,300,RC,86361,HCPCS,Outpatient,,,142.2,85.32,,94.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.54,70,,,percent of total billed charges,70% of total billed charges,106.65,75,,,percent of total billed charges,75% of total billed charges,48.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,113.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.73,350,,,Fee Schedule,350% of CMS OPPS Rate,27.31,102,,,Fee Schedule,102% of CMS OPPS Rate,108.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,63.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,29.75,100,,,Fee Schedule,100% of UHC Fee Schedule,99.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,61.59,230,,,Fee Schedule,230% of CMS OPPS Rate,68.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,127.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,100,,,Fee Schedule,100% of CMS OPPS Rate,26.78,127.98,
WBC WHITE BLD CELL COUNT BLD,4087144,CDM,305,RC,85048,HCPCS,Outpatient,,,116.6,69.96,,8.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,4.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,350,,,Fee Schedule,350% of CMS OPPS Rate,2.59,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,5.84,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2.54,104.94,
"HIV-1 ACCUQUANT, RNA, SER",4087144,CDM,306,RC,87536,HCPCS,Outpatient,,,255,153,,301.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,84.91,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,85.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,178.5,70,,,percent of total billed charges,70% of total billed charges,191.25,75,,,percent of total billed charges,75% of total billed charges,153.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,297.84,350,,,Fee Schedule,350% of CMS OPPS Rate,86.8,102,,,Fee Schedule,102% of CMS OPPS Rate,195.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,114.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,94.55,100,,,Fee Schedule,100% of UHC Fee Schedule,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,195.73,230,,,Fee Schedule,230% of CMS OPPS Rate,122.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,229.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,84.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,100,,,Fee Schedule,100% of CMS OPPS Rate,84.91,301.25,
Blood test to determine the concentration of lead in the blood,4087145,CDM,301,RC,83655,HCPCS,Outpatient,,,58,34.8,,42.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,21.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.38,350,,,Fee Schedule,350% of CMS OPPS Rate,12.35,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,13.46,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,52.2,
MERCURY QUANTITATIVE,4087145,CDM,301,RC,83825,HCPCS,Outpatient,,,106.15,63.69,,57.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,29.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.91,350,,,Fee Schedule,350% of CMS OPPS Rate,16.58,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,18.06,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.39,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,95.54,
ARSENIC (HEAVY METAL),4087145,CDM,301,RC,82175,HCPCS,Outpatient,,,106.15,63.69,,67.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,34.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.39,350,,,Fee Schedule,350% of CMS OPPS Rate,19.34,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,21.08,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,43.63,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,95.54,
Blood test to determine the concentration of lead in the blood,4087146,CDM,301,RC,83655,HCPCS,Outpatient,,,58,34.8,,42.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,21.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.38,350,,,Fee Schedule,350% of CMS OPPS Rate,12.35,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,13.46,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,52.2,
ARSENIC (HEAVY METAL),4087146,CDM,301,RC,82175,HCPCS,Outpatient,,,106.15,63.69,,67.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,34.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.39,350,,,Fee Schedule,350% of CMS OPPS Rate,19.34,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,21.08,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,43.63,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,95.54,
MERCURY QUANTITATIVE,4087146,CDM,301,RC,83825,HCPCS,Outpatient,,,106.15,63.69,,57.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,29.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.91,350,,,Fee Schedule,350% of CMS OPPS Rate,16.58,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,18.06,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.39,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,95.54,
CULTURE TYPING ID BY DNA OR RNA,4087149,CDM,309,RC,87149,HCPCS,Outpatient,,,184,110.4,,70.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,36.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.17,350,,,Fee Schedule,350% of CMS OPPS Rate,20.45,102,,,Fee Schedule,102% of CMS OPPS Rate,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of UHC Fee Schedule,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.11,230,,,Fee Schedule,230% of CMS OPPS Rate,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,165.6,
Blood test to determine the concentration of lead in the blood,4087150,CDM,301,RC,83655,HCPCS,Outpatient,,,58,34.8,,42.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,21.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.38,350,,,Fee Schedule,350% of CMS OPPS Rate,12.35,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,13.46,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,52.2,
MERCURY QUANTITATIVE,4087150,CDM,301,RC,83825,HCPCS,Outpatient,,,106.15,63.69,,57.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,29.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.91,350,,,Fee Schedule,350% of CMS OPPS Rate,16.58,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,18.06,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,37.39,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,100,,,Fee Schedule,100% of CMS OPPS Rate,16.26,95.54,
ARSENIC (HEAVY METAL),4087150,CDM,301,RC,82175,HCPCS,Outpatient,,,106.15,63.69,,67.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,34.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.39,350,,,Fee Schedule,350% of CMS OPPS Rate,19.34,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,21.08,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,43.63,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,95.54,
HERPES SIMPLES L AG,4087151,CDM,306,RC,87274,HCPCS,Outpatient,,,33,19.8,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.1,70,,,percent of total billed charges,70% of total billed charges,24.75,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,25.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,15.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,42.4,
INFECTIOUS AGENT AG HERPES2,4087151,CDM,309,RC,87273,HCPCS,Outpatient,,,80,48,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,72,
HERPES S.VIRUS QUANT,4087153,CDM,300,RC,87530,HCPCS,Outpatient,,,129,77.4,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.3,70,,,percent of total billed charges,70% of total billed charges,96.75,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,98.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,58.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,61.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,116.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,151.65,
HERPES SIMPLEX DNA PROBE,4087154,CDM,300,RC,87529,HCPCS,Outpatient,,,242.55,145.53,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,169.79,70,,,percent of total billed charges,70% of total billed charges,181.91,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,194.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,185.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,169.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,116.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,218.3,
Test to determine levels of immunoglobulins in the blood,4087156,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
ISLET CELL ABS,4087158,CDM,302,RC,86341,HCPCS,Outpatient,,,71,42.6,,83.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49.7,70,,,percent of total billed charges,70% of total billed charges,53.25,75,,,percent of total billed charges,75% of total billed charges,42.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.49,350,,,Fee Schedule,350% of CMS OPPS Rate,24.04,102,,,Fee Schedule,102% of CMS OPPS Rate,54.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of UHC Fee Schedule,49.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,54.21,230,,,Fee Schedule,230% of CMS OPPS Rate,34.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,63.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,23.57,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,83.43,
ANTI-LEGION PNEUMOPH AB,4087160,CDM,302,RC,86713,HCPCS,Outpatient,,,36.85,22.11,,54.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.8,70,,,percent of total billed charges,70% of total billed charges,27.64,75,,,percent of total billed charges,75% of total billed charges,27.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.55,350,,,Fee Schedule,350% of CMS OPPS Rate,15.6,102,,,Fee Schedule,102% of CMS OPPS Rate,28.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,17,100,,,Fee Schedule,100% of UHC Fee Schedule,25.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.19,230,,,Fee Schedule,230% of CMS OPPS Rate,17.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,33.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,54.16,
LYPHOCYTES/GATED CELLS,4087163,CDM,302,RC,86359,HCPCS,Outpatient,,,127,76.2,,133.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,67.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.05,350,,,Fee Schedule,350% of CMS OPPS Rate,38.48,102,,,Fee Schedule,102% of CMS OPPS Rate,97.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of UHC Fee Schedule,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,230,,,Fee Schedule,230% of CMS OPPS Rate,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,114.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,133.56,
CD4(HELPER/INDUCER),4087163,CDM,302,RC,86360,HCPCS,Outpatient,,,141,84.6,,166.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.28,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges,105.75,75,,,percent of total billed charges,75% of total billed charges,84.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.43,350,,,Fee Schedule,350% of CMS OPPS Rate,47.91,102,,,Fee Schedule,102% of CMS OPPS Rate,107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,63.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.21,100,,,Fee Schedule,100% of UHC Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,108.05,230,,,Fee Schedule,230% of CMS OPPS Rate,67.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,166.3,
B CELL TOTAL COUNT,4087163,CDM,302,RC,86355,HCPCS,Outpatient,,,113,67.8,,133.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,67.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.05,350,,,Fee Schedule,350% of CMS OPPS Rate,38.48,102,,,Fee Schedule,102% of CMS OPPS Rate,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of UHC Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,230,,,Fee Schedule,230% of CMS OPPS Rate,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,133.56,
LYPHOCYTES/GATED CELLS,4087165,CDM,302,RC,86359,HCPCS,Outpatient,,,127,76.2,,133.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.9,70,,,percent of total billed charges,70% of total billed charges,95.25,75,,,percent of total billed charges,75% of total billed charges,67.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132.05,350,,,Fee Schedule,350% of CMS OPPS Rate,38.48,102,,,Fee Schedule,102% of CMS OPPS Rate,97.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,57.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of UHC Fee Schedule,88.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,230,,,Fee Schedule,230% of CMS OPPS Rate,60.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,114.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,100,,,Fee Schedule,100% of CMS OPPS Rate,37.72,133.56,
CD4(HELPER/INDUCER),4087165,CDM,302,RC,86360,HCPCS,Outpatient,,,141,84.6,,166.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.28,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges,105.75,75,,,percent of total billed charges,75% of total billed charges,84.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.43,350,,,Fee Schedule,350% of CMS OPPS Rate,47.91,102,,,Fee Schedule,102% of CMS OPPS Rate,107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,63.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,52.21,100,,,Fee Schedule,100% of UHC Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,108.05,230,,,Fee Schedule,230% of CMS OPPS Rate,67.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,166.3,
Blood test to determine if antibodies exist for measles,4087168,CDM,302,RC,86765,HCPCS,Outpatient,,,62,37.2,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,55.8,
METANEPHRINES,4087169,CDM,301,RC,83835,HCPCS,Outpatient,,,88,52.8,,59.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,30.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.29,350,,,Fee Schedule,350% of CMS OPPS Rate,17.27,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,18.83,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,38.96,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,100,,,Fee Schedule,100% of CMS OPPS Rate,16.94,79.2,
Test to measure creatinine in the urine,4087169,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
ALBUMIN MISC SPECIMEN,4087170,CDM,301,RC,82042,HCPCS,Outpatient,,,87.75,52.65,,27.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.23,350,,,Fee Schedule,350% of CMS OPPS Rate,7.93,102,,,Fee Schedule,102% of CMS OPPS Rate,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7,100,,,Fee Schedule,100% of UHC Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,230,,,Fee Schedule,230% of CMS OPPS Rate,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,7.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,78.98,
ALBUMIN BLOOD,4087170,CDM,301,RC,82040,HCPCS,Outpatient,,,90.9,54.54,,17.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,8.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,350,,,Fee Schedule,350% of CMS OPPS Rate,5.04,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,81.81,
Test to determine levels of immunoglobulins in the blood,4087170,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
OLIGOCL IMMGLOB (MS PNL),4087170,CDM,301,RC,83916,HCPCS,Outpatient,,,82,49.2,,96.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,49.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.86,350,,,Fee Schedule,350% of CMS OPPS Rate,27.93,102,,,Fee Schedule,102% of CMS OPPS Rate,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.65,100,,,Fee Schedule,100% of UHC Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,62.99,230,,,Fee Schedule,230% of CMS OPPS Rate,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,27.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.12,96.96,
MYELIN BASIC PROTEIN,4087170,CDM,301,RC,83873,HCPCS,Outpatient,,,52,31.2,,60.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.4,70,,,percent of total billed charges,70% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,30.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.2,350,,,Fee Schedule,350% of CMS OPPS Rate,17.54,102,,,Fee Schedule,102% of CMS OPPS Rate,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,19.12,100,,,Fee Schedule,100% of UHC Fee Schedule,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,39.56,230,,,Fee Schedule,230% of CMS OPPS Rate,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.2,60.88,
IMMUNOASSAY RAD TECHNIQUE,4087171,CDM,300,RC,83519,HCPCS,Outpatient,,,149.05,89.43,,65.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,33.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.39,350,,,Fee Schedule,350% of CMS OPPS Rate,18.76,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,100,,,Fee Schedule,100% of UHC Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.32,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,134.15,
FLORESCENT CHEM ABS,4087171,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
ANTI MYCOPLASMA PNEUM  AB,4087172,CDM,302,RC,86738,HCPCS,Outpatient,,,181.35,108.81,,46.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges,136.01,75,,,percent of total billed charges,75% of total billed charges,23.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.34,350,,,Fee Schedule,350% of CMS OPPS Rate,13.5,102,,,Fee Schedule,102% of CMS OPPS Rate,138.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of UHC Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,30.45,230,,,Fee Schedule,230% of CMS OPPS Rate,87.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,163.22,
Blood test for an STD,4087173,CDM,306,RC,87591,HCPCS,Outpatient,,,185.4,111.24,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges,139.05,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,141.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,88.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,166.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,166.86,
Test that detects Chlamydia,4087173,CDM,300,RC,87491,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
OVA & PARASITE EXAM,4087174,CDM,306,RC,87177,HCPCS,Outpatient,,,63.8,38.28,,31.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.66,70,,,percent of total billed charges,70% of total billed charges,47.85,75,,,percent of total billed charges,75% of total billed charges,16.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.15,350,,,Fee Schedule,350% of CMS OPPS Rate,9.07,102,,,Fee Schedule,102% of CMS OPPS Rate,48.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of UHC Fee Schedule,44.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,230,,,Fee Schedule,230% of CMS OPPS Rate,30.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,57.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,57.42,
"SMEAR, COMPLEX STAIN",4087174,CDM,306,RC,87209,HCPCS,Outpatient,,,54,32.4,,63.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.93,350,,,Fee Schedule,350% of CMS OPPS Rate,18.33,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.97,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,41.35,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,63.64,
ANTIBODY ID LEUKOCYTE ABS,4087175,CDM,302,RC,86021,HCPCS,Outpatient,,,54.45,32.67,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
ANA(REFLEX TITER),4087175,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
PARVOVIRUS AB  EA,4087176,CDM,302,RC,86747,HCPCS,Outpatient,,,56.65,33.99,,53.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.66,70,,,percent of total billed charges,70% of total billed charges,42.49,75,,,percent of total billed charges,75% of total billed charges,27.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.6,350,,,Fee Schedule,350% of CMS OPPS Rate,15.33,102,,,Fee Schedule,102% of CMS OPPS Rate,43.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16.7,100,,,Fee Schedule,100% of UHC Fee Schedule,39.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,34.56,230,,,Fee Schedule,230% of CMS OPPS Rate,27.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,100,,,Fee Schedule,100% of CMS OPPS Rate,15.03,53.2,
OVA & PARASITE EXAM,4087177,CDM,306,RC,87177,HCPCS,Outpatient,,,63.8,38.28,,31.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.66,70,,,percent of total billed charges,70% of total billed charges,47.85,75,,,percent of total billed charges,75% of total billed charges,16.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.15,350,,,Fee Schedule,350% of CMS OPPS Rate,9.07,102,,,Fee Schedule,102% of CMS OPPS Rate,48.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,28.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of UHC Fee Schedule,44.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,20.47,230,,,Fee Schedule,230% of CMS OPPS Rate,30.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,57.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.9,57.42,
"TUBERCLE BACILLUS, MIC",4087190,CDM,306,RC,87190,HCPCS,Outpatient,,,16,9.6,,25.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,13.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.58,350,,,Fee Schedule,350% of CMS OPPS Rate,7.45,102,,,Fee Schedule,102% of CMS OPPS Rate,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6.58,100,,,Fee Schedule,100% of UHC Fee Schedule,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,16,230,,,Fee Schedule,230% of CMS OPPS Rate,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6.58,25.87,
PROTEIN ELECT.URINE RAND,4087191,CDM,300,RC,84166,HCPCS,Outpatient,,,261,156.6,,63.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges,195.75,75,,,percent of total billed charges,75% of total billed charges,32.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,350,,,Fee Schedule,350% of CMS OPPS Rate,18.18,102,,,Fee Schedule,102% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,100,,,Fee Schedule,100% of UHC Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,41,230,,,Fee Schedule,230% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,234.9,
PROTEIN TOTAL URINE,4087191,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
PSA (prostate specific antigen),4087192,CDM,301,RC,84153,HCPCS,Outpatient,,,77.55,46.53,,65.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.29,70,,,percent of total billed charges,70% of total billed charges,58.16,75,,,percent of total billed charges,75% of total billed charges,33.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.36,350,,,Fee Schedule,350% of CMS OPPS Rate,18.75,102,,,Fee Schedule,102% of CMS OPPS Rate,59.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,34.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,54.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.29,230,,,Fee Schedule,230% of CMS OPPS Rate,37.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,69.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,69.8,
PSA (prostate specific antigen) measurement,4087192,CDM,301,RC,84154,HCPCS,Outpatient,,,55,33,,65.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.5,70,,,percent of total billed charges,70% of total billed charges,41.25,75,,,percent of total billed charges,75% of total billed charges,33.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.36,350,,,Fee Schedule,350% of CMS OPPS Rate,18.75,102,,,Fee Schedule,102% of CMS OPPS Rate,42.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,24.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,100,,,Fee Schedule,100% of UHC Fee Schedule,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.29,230,,,Fee Schedule,230% of CMS OPPS Rate,26.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,49.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,65.1,
CALCIUM SERUM,4087193,CDM,301,RC,82310,HCPCS,Outpatient,,,88.65,53.19,,18.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,9.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.06,350,,,Fee Schedule,350% of CMS OPPS Rate,5.26,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.73,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,100,,,Fee Schedule,100% of CMS OPPS Rate,5.16,79.79,
CALCIUM IONIZED ABGS,4087193,CDM,301,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
PARATHORMONE,4087193,CDM,301,RC,83970,HCPCS,Outpatient,,,124,74.4,,146.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,103.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,74.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.48,350,,,Fee Schedule,350% of CMS OPPS Rate,42.1,102,,,Fee Schedule,102% of CMS OPPS Rate,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,45.86,100,,,Fee Schedule,100% of UHC Fee Schedule,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,94.94,230,,,Fee Schedule,230% of CMS OPPS Rate,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,100,,,Fee Schedule,100% of CMS OPPS Rate,41.28,146.13,
"ANTIBODY INFLU,RICKETTSIA",4087195,CDM,302,RC,86757,HCPCS,Outpatient,,,58,34.8,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,68.49,
SACCHAROMYCES CEREVIS.ABS,4087196,CDM,300,RC,86671,HCPCS,Outpatient,,,128.15,76.89,,43.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges,96.11,75,,,percent of total billed charges,75% of total billed charges,22.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,350,,,Fee Schedule,350% of CMS OPPS Rate,12.49,102,,,Fee Schedule,102% of CMS OPPS Rate,98.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,57.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of UHC Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,230,,,Fee Schedule,230% of CMS OPPS Rate,61.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,115.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,115.34,
EXTRACTABLE N AG IGG ABS,4087198,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
"TESTOSTERONE, FREE",4087199,CDM,300,RC,84402,HCPCS,Outpatient,,,184.8,110.88,,90.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.36,70,,,percent of total billed charges,70% of total billed charges,138.6,75,,,percent of total billed charges,75% of total billed charges,45.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.14,350,,,Fee Schedule,350% of CMS OPPS Rate,25.97,102,,,Fee Schedule,102% of CMS OPPS Rate,141.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,83.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.31,100,,,Fee Schedule,100% of UHC Fee Schedule,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,58.58,230,,,Fee Schedule,230% of CMS OPPS Rate,88.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,166.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,166.32,
TESTOSTERONE SERUM,4087199,CDM,301,RC,84403,HCPCS,Outpatient,,,113.3,67.98,,91.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,46.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.33,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,28.68,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.36,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,101.97,
"TESTOSTERONE, FREE",4087200,CDM,300,RC,84402,HCPCS,Outpatient,,,184.8,110.88,,90.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.36,70,,,percent of total billed charges,70% of total billed charges,138.6,75,,,percent of total billed charges,75% of total billed charges,45.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.14,350,,,Fee Schedule,350% of CMS OPPS Rate,25.97,102,,,Fee Schedule,102% of CMS OPPS Rate,141.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,83.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.31,100,,,Fee Schedule,100% of UHC Fee Schedule,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,58.58,230,,,Fee Schedule,230% of CMS OPPS Rate,88.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,166.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,166.32,
TESTOSTERONE SERUM,4087200,CDM,301,RC,84403,HCPCS,Outpatient,,,113.3,67.98,,91.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,46.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.33,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,28.68,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.36,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,101.97,
IMMUNOASSAY ANALYTE,4087203,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
Test to measure creatinine in the urine,4087204,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
PROTEIN TOTAL URINE,4087204,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
PROTEIN ELECT.URINE RAND,4087204,CDM,300,RC,84166,HCPCS,Outpatient,,,261,156.6,,63.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges,195.75,75,,,percent of total billed charges,75% of total billed charges,32.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,350,,,Fee Schedule,350% of CMS OPPS Rate,18.18,102,,,Fee Schedule,102% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,100,,,Fee Schedule,100% of UHC Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,41,230,,,Fee Schedule,230% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,234.9,
VON WILLEBRAND FACT AG,4087205,CDM,305,RC,85246,HCPCS,Outpatient,,,193.05,115.83,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,173.75,
VON WILLEBRAND MULTIMERS,4087205,CDM,305,RC,85247,HCPCS,Outpatient,,,91.3,54.78,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges,68.48,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,69.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,43.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,82.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,82.17,
RISTOCETIN COFACTOR,4087205,CDM,305,RC,85245,HCPCS,Outpatient,,,91.3,54.78,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges,68.48,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,69.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,43.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,82.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,82.17,
"FACTOR VIII ASSAY, PLASMA",4087205,CDM,305,RC,85240,HCPCS,Outpatient,,,304.2,182.52,,63.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.94,70,,,percent of total billed charges,70% of total billed charges,228.15,75,,,percent of total billed charges,75% of total billed charges,32.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,243.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.64,350,,,Fee Schedule,350% of CMS OPPS Rate,18.25,102,,,Fee Schedule,102% of CMS OPPS Rate,232.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,100,,,Fee Schedule,100% of UHC Fee Schedule,212.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.17,230,,,Fee Schedule,230% of CMS OPPS Rate,146.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,273.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,273.78,
Coagulation assessment blood test,4087205,CDM,305,RC,85730,HCPCS,Outpatient,,,152.1,91.26,,21.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,10.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.03,350,,,Fee Schedule,350% of CMS OPPS Rate,6.13,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,136.89,
ANTI HERPES II IGG AB,4087206,CDM,302,RC,86694,HCPCS,Outpatient,,,218.5,131.1,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.95,70,,,percent of total billed charges,70% of total billed charges,163.88,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,174.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,167.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,98.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,152.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,152.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,104.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,196.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,196.65,
HERPES SIM.VIRUS 1 ABS,4087206,CDM,302,RC,86695,HCPCS,Outpatient,,,45.1,27.06,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
TOXOPLASMA (TOXO AB),4087206,CDM,302,RC,86777,HCPCS,Outpatient,,,66.15,39.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.81,59.54,
"TOXOPLASMA, IGM ABS",4087206,CDM,302,RC,86778,HCPCS,Outpatient,,,66.15,39.69,,51.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.43,350,,,Fee Schedule,350% of CMS OPPS Rate,14.69,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,33.14,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,59.54,
HERPES SIMPLEX 2 ABS,4087206,CDM,302,RC,86696,HCPCS,Outpatient,,,240.35,144.21,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges,180.26,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,183.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,108.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,115.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,216.32,
Blood test to monitor for cytomegalovirus,4087206,CDM,302,RC,86644,HCPCS,Outpatient,,,106.15,63.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,95.54,
"ANTI-CMV AB,IGM",4087206,CDM,302,RC,86645,HCPCS,Outpatient,,,106.15,63.69,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,95.54,
Blood test to determine if antibodies exist for rubella,4087206,CDM,302,RC,86762,HCPCS,Outpatient,,,43,25.8,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,50.94,
"SMEAR, COMPLEX STAIN",4087209,CDM,306,RC,87209,HCPCS,Outpatient,,,54,32.4,,63.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.93,350,,,Fee Schedule,350% of CMS OPPS Rate,18.33,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.97,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,41.35,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,63.64,
"VITAMIN, NOS",4087210,CDM,301,RC,84591,HCPCS,Outpatient,,,84.15,50.49,,60.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.13,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.91,70,,,percent of total billed charges,70% of total billed charges,63.11,75,,,percent of total billed charges,75% of total billed charges,30.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,67.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.71,350,,,Fee Schedule,350% of CMS OPPS Rate,17.4,102,,,Fee Schedule,102% of CMS OPPS Rate,64.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,37.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.35,100,,,Fee Schedule,100% of UHC Fee Schedule,58.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,39.23,230,,,Fee Schedule,230% of CMS OPPS Rate,40.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,75.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.35,75.74,
VITAMIN E,4087210,CDM,301,RC,84446,HCPCS,Outpatient,,,89.1,53.46,,50.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges,66.83,75,,,percent of total billed charges,75% of total billed charges,25.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.63,350,,,Fee Schedule,350% of CMS OPPS Rate,14.46,102,,,Fee Schedule,102% of CMS OPPS Rate,68.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,15.76,100,,,Fee Schedule,100% of UHC Fee Schedule,62.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,32.61,230,,,Fee Schedule,230% of CMS OPPS Rate,42.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,100,,,Fee Schedule,100% of CMS OPPS Rate,14.18,80.19,
"ANTIBODY INFLU,RICKETTSIA",4087211,CDM,302,RC,86757,HCPCS,Outpatient,,,58,34.8,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,68.49,
"ANTI-THYROGLOBULIN AB,SER",4087212,CDM,302,RC,86800,HCPCS,Outpatient,,,95.7,57.42,,56.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.91,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,28.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.68,350,,,Fee Schedule,350% of CMS OPPS Rate,16.22,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,36.59,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,86.13,
THYROGLOBULIN,4087212,CDM,301,RC,84432,HCPCS,Outpatient,,,125.95,75.57,,56.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.17,70,,,percent of total billed charges,70% of total billed charges,94.46,75,,,percent of total billed charges,75% of total billed charges,28.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.21,350,,,Fee Schedule,350% of CMS OPPS Rate,16.38,102,,,Fee Schedule,102% of CMS OPPS Rate,96.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.85,100,,,Fee Schedule,100% of UHC Fee Schedule,88.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,230,,,Fee Schedule,230% of CMS OPPS Rate,60.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,113.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,113.36,
BORRELIA B. ABS,4087213,CDM,302,RC,86618,HCPCS,Outpatient,,,152.35,91.41,,60.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,30.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.6,350,,,Fee Schedule,350% of CMS OPPS Rate,17.37,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,18.92,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,39.16,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,100,,,Fee Schedule,100% of CMS OPPS Rate,17.03,137.12,
BORRELIA B. ABS CONFIRM,4087213,CDM,302,RC,86617,HCPCS,Outpatient,,,54.45,32.67,,54.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.21,350,,,Fee Schedule,350% of CMS OPPS Rate,15.79,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,35.62,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,54.83,
SEX HORMONE BINDING GLOB.,4087216,CDM,300,RC,84270,HCPCS,Outpatient,,,70.4,42.24,,76.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49.28,70,,,percent of total billed charges,70% of total billed charges,52.8,75,,,percent of total billed charges,75% of total billed charges,39.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.05,350,,,Fee Schedule,350% of CMS OPPS Rate,22.16,102,,,Fee Schedule,102% of CMS OPPS Rate,53.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,24.15,100,,,Fee Schedule,100% of UHC Fee Schedule,49.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,49.97,230,,,Fee Schedule,230% of CMS OPPS Rate,33.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,63.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.24,76.92,
TESTOSTERONE SERUM,4087216,CDM,301,RC,84403,HCPCS,Outpatient,,,113.3,67.98,,91.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges,84.98,75,,,percent of total billed charges,75% of total billed charges,46.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.33,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,86.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,50.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,28.68,100,,,Fee Schedule,100% of UHC Fee Schedule,79.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.36,230,,,Fee Schedule,230% of CMS OPPS Rate,54.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,101.97,
ALBUMIN BLOOD,4087216,CDM,301,RC,82040,HCPCS,Outpatient,,,90.9,54.54,,17.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,8.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,350,,,Fee Schedule,350% of CMS OPPS Rate,5.04,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,81.81,
IMMUNOGLOBULIN LIGHT CHAINS FREE EA,4087217,CDM,300,RC,83521,HCPCS,Outpatient,,,216,129.6,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,108,50,,,percent of total billed charges,pays at 50% of total billed charges,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,108,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.95,194.4,
"WEST NILE VIRUS AB, IGM",4087219,CDM,302,RC,86788,HCPCS,Outpatient,,,60,36,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42,70,,,percent of total billed charges,70% of total billed charges,45,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,45.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,100,,,Fee Schedule,100% of UHC Fee Schedule,42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,28.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,59.64,
WEST NILE VIRUS ANTIBODY,4087219,CDM,302,RC,86789,HCPCS,Outpatient,,,43,25.8,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,50.94,
WESTERN EQUINE ENCEPH ABS,4087220,CDM,302,RC,86654,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
ST LOUIS ENCEPH. ABS,4087220,CDM,302,RC,86653,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
EASTERN EQUINE ENCEPH ABS,4087220,CDM,302,RC,86652,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
CALIF LA CROSSE VIRUS ENC,4087220,CDM,302,RC,86651,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
WESTERN EQUINE ENCEPH ABS,4087221,CDM,302,RC,86654,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
ST LOUIS ENCEPH. ABS,4087221,CDM,302,RC,86653,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
EASTERN EQUINE ENCEPH ABS,4087221,CDM,302,RC,86652,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
CALIF LA CROSSE VIRUS ENC,4087221,CDM,302,RC,86651,HCPCS,Outpatient,,,31.95,19.17,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges,23.96,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,24.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,22.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
ASPERGILLUS ABS,4087225,CDM,302,RC,86606,HCPCS,Outpatient,,,50.6,30.36,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
IGG SPECIFIC ALLERGINS,4087225,CDM,302,RC,86001,HCPCS,Outpatient,,,33.55,20.13,,27.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.49,70,,,percent of total billed charges,70% of total billed charges,25.16,75,,,percent of total billed charges,75% of total billed charges,14.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.37,350,,,Fee Schedule,350% of CMS OPPS Rate,7.97,102,,,Fee Schedule,102% of CMS OPPS Rate,25.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.04,100,,,Fee Schedule,100% of UHC Fee Schedule,23.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.98,230,,,Fee Schedule,230% of CMS OPPS Rate,16.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.04,30.2,
"BACTERIUM ABS,IMMUNOASSAY",4087225,CDM,300,RC,86609,HCPCS,Outpatient,,,39,23.4,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,45.59,
Blood test to determine cause of inappropriate blood clot formation,4087226,CDM,302,RC,86147,HCPCS,Outpatient,,,139.7,83.82,,90.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges,104.78,75,,,percent of total billed charges,75% of total billed charges,45.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.07,350,,,Fee Schedule,350% of CMS OPPS Rate,25.95,102,,,Fee Schedule,102% of CMS OPPS Rate,106.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,62.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,100,,,Fee Schedule,100% of UHC Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.53,230,,,Fee Schedule,230% of CMS OPPS Rate,67.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,125.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,125.73,
IGG SUBCLASS,4087228,CDM,301,RC,82787,HCPCS,Outpatient,,,93.5,56.1,,28.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.45,70,,,percent of total billed charges,70% of total billed charges,70.13,75,,,percent of total billed charges,75% of total billed charges,14.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.07,350,,,Fee Schedule,350% of CMS OPPS Rate,8.18,102,,,Fee Schedule,102% of CMS OPPS Rate,71.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,42.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.91,100,,,Fee Schedule,100% of UHC Fee Schedule,65.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,18.44,230,,,Fee Schedule,230% of CMS OPPS Rate,44.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,84.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6.75,84.15,
Test to determine levels of immunoglobulins in the blood,4087228,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
Coagulation assessment blood test,4087229,CDM,305,RC,85730,HCPCS,Outpatient,,,152.1,91.26,,21.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,10.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.03,350,,,Fee Schedule,350% of CMS OPPS Rate,6.13,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,136.89,
"Blood test, clotting time",4087229,CDM,305,RC,85610,HCPCS,Outpatient,,,67.95,40.77,,15.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.57,70,,,percent of total billed charges,70% of total billed charges,50.96,75,,,percent of total billed charges,75% of total billed charges,7.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.01,350,,,Fee Schedule,350% of CMS OPPS Rate,4.37,102,,,Fee Schedule,102% of CMS OPPS Rate,51.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,30.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,47.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,9.86,230,,,Fee Schedule,230% of CMS OPPS Rate,32.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,61.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,61.16,
"TOXIN, TISSUE CULTURE",4087230,CDM,306,RC,87230,HCPCS,Outpatient,,,63,37.8,,69.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,35.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.08,350,,,Fee Schedule,350% of CMS OPPS Rate,20.13,102,,,Fee Schedule,102% of CMS OPPS Rate,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,21.93,100,,,Fee Schedule,100% of UHC Fee Schedule,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,45.4,230,,,Fee Schedule,230% of CMS OPPS Rate,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.73,69.87,
MASS SPECTROMETRY QUAL/QUANT,4087231,CDM,301,RC,83789,HCPCS,Outpatient,,,122,73.2,,85.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.4,70,,,percent of total billed charges,70% of total billed charges,91.5,75,,,percent of total billed charges,75% of total billed charges,43.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.38,350,,,Fee Schedule,350% of CMS OPPS Rate,24.59,102,,,Fee Schedule,102% of CMS OPPS Rate,93.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of UHC Fee Schedule,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,55.45,230,,,Fee Schedule,230% of CMS OPPS Rate,58.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,109.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,24.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21.7,109.8,
BRUCELLA ABORTUS ABS,4087232,CDM,302,RC,86622,HCPCS,Outpatient,,,36,21.6,,31.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges,27,75,,,percent of total billed charges,75% of total billed charges,16.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,28.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.25,350,,,Fee Schedule,350% of CMS OPPS Rate,9.1,102,,,Fee Schedule,102% of CMS OPPS Rate,27.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,16.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.93,100,,,Fee Schedule,100% of UHC Fee Schedule,25.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,20.53,230,,,Fee Schedule,230% of CMS OPPS Rate,17.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,32.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,100,,,Fee Schedule,100% of CMS OPPS Rate,8.93,32.4,
ESTRONE,4087233,CDM,301,RC,82679,HCPCS,Outpatient,,,81.45,48.87,,88.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.02,70,,,percent of total billed charges,70% of total billed charges,61.09,75,,,percent of total billed charges,75% of total billed charges,44.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.32,350,,,Fee Schedule,350% of CMS OPPS Rate,25.44,102,,,Fee Schedule,102% of CMS OPPS Rate,62.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,27.73,100,,,Fee Schedule,100% of UHC Fee Schedule,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,57.38,230,,,Fee Schedule,230% of CMS OPPS Rate,39.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,73.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,88.32,
Blood test to measure a type of estrogen in the blood,4087233,CDM,301,RC,82670,HCPCS,Outpatient,,,166.1,99.66,,98.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,116.27,70,,,percent of total billed charges,70% of total billed charges,124.58,75,,,percent of total billed charges,75% of total billed charges,50.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.79,350,,,Fee Schedule,350% of CMS OPPS Rate,28.49,102,,,Fee Schedule,102% of CMS OPPS Rate,127.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.04,100,,,Fee Schedule,100% of UHC Fee Schedule,116.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,64.26,230,,,Fee Schedule,230% of CMS OPPS Rate,79.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,149.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,149.49,
ESTRIOL(ALPHA FETOPROTEIN,4087233,CDM,301,RC,82677,HCPCS,Outpatient,,,73,43.8,,85.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.1,70,,,percent of total billed charges,70% of total billed charges,54.75,75,,,percent of total billed charges,75% of total billed charges,43.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.63,350,,,Fee Schedule,350% of CMS OPPS Rate,24.66,102,,,Fee Schedule,102% of CMS OPPS Rate,55.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,32.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,26.87,100,,,Fee Schedule,100% of UHC Fee Schedule,51.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,55.61,230,,,Fee Schedule,230% of CMS OPPS Rate,35.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,65.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,100,,,Fee Schedule,100% of CMS OPPS Rate,24.18,85.59,
COLLAGEN CROSS LINKS,4087234,CDM,301,RC,82523,HCPCS,Outpatient,,,62.15,37.29,,66.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.51,70,,,percent of total billed charges,70% of total billed charges,46.61,75,,,percent of total billed charges,75% of total billed charges,33.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.38,350,,,Fee Schedule,350% of CMS OPPS Rate,19.05,102,,,Fee Schedule,102% of CMS OPPS Rate,47.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,27.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,20.76,100,,,Fee Schedule,100% of UHC Fee Schedule,43.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,42.96,230,,,Fee Schedule,230% of CMS OPPS Rate,29.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,55.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,66.12,
Test to measure creatinine in the urine,4087234,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
GENOTYPE ANALYSIS BY DNA HIV1,4087235,CDM,306,RC,87906,HCPCS,Outpatient,,,878,526.8,,455.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,128.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,128.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,324.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,614.6,70,,,percent of total billed charges,70% of total billed charges,658.5,75,,,percent of total billed charges,75% of total billed charges,231.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,702.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.55,350,,,Fee Schedule,350% of CMS OPPS Rate,131.3,102,,,Fee Schedule,102% of CMS OPPS Rate,671.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,395.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,614.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,526.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,143.03,100,,,Fee Schedule,100% of UHC Fee Schedule,614.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,296.07,230,,,Fee Schedule,230% of CMS OPPS Rate,421.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,790.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,790.2,
INFECTIOUS AGENT GENOTYPE,4087235,CDM,309,RC,87901,HCPCS,Outpatient,,,772,463.2,,911.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,257.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,648.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,540.4,70,,,percent of total billed charges,70% of total billed charges,579,75,,,percent of total billed charges,75% of total billed charges,463.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.07,350,,,Fee Schedule,350% of CMS OPPS Rate,262.59,102,,,Fee Schedule,102% of CMS OPPS Rate,590.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,347.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,540.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,463.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,286.06,100,,,Fee Schedule,100% of UHC Fee Schedule,540.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,592.13,230,,,Fee Schedule,230% of CMS OPPS Rate,370.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,694.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,911.37,
"PHENOTYPE, DNA HIV W/CLT",4087236,CDM,306,RC,87904,HCPCS,Outpatient,,,66,39.6,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.2,70,,,percent of total billed charges,70% of total billed charges,49.5,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,28.96,100,,,Fee Schedule,100% of UHC Fee Schedule,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,92.28,
"PHENOTYPE, DNA HIV W/CULT",4087236,CDM,306,RC,87903,HCPCS,Outpatient,,,916,549.6,,1729.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,488.66,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,488.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1230.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,641.2,70,,,percent of total billed charges,70% of total billed charges,687,75,,,percent of total billed charges,75% of total billed charges,879.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1710.31,350,,,Fee Schedule,350% of CMS OPPS Rate,498.43,102,,,Fee Schedule,102% of CMS OPPS Rate,700.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,412.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,641.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,549.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,542.95,100,,,Fee Schedule,100% of UHC Fee Schedule,641.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,916,230,,,Fee Schedule,230% of CMS OPPS Rate,439.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,824.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,412.2,1729.85,
"CULTURE, AFB",4087237,CDM,306,RC,87116,HCPCS,Outpatient,,,57.6,34.56,,38.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges,43.2,75,,,percent of total billed charges,75% of total billed charges,19.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,350,,,Fee Schedule,350% of CMS OPPS Rate,11.01,102,,,Fee Schedule,102% of CMS OPPS Rate,44.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,25.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.01,100,,,Fee Schedule,100% of UHC Fee Schedule,40.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,24.84,230,,,Fee Schedule,230% of CMS OPPS Rate,27.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,51.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10.8,51.84,
"CONCENTRATION,MICRO",4087237,CDM,306,RC,87015,HCPCS,Outpatient,,,48.15,28.89,,23.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges,36.11,75,,,percent of total billed charges,75% of total billed charges,12.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.38,350,,,Fee Schedule,350% of CMS OPPS Rate,6.81,102,,,Fee Schedule,102% of CMS OPPS Rate,36.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of UHC Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,230,,,Fee Schedule,230% of CMS OPPS Rate,23.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,43.34,
IMMUNOASSAY RAD TECHNIQUE,4087238,CDM,300,RC,83519,HCPCS,Outpatient,,,149.05,89.43,,65.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,33.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.39,350,,,Fee Schedule,350% of CMS OPPS Rate,18.76,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,100,,,Fee Schedule,100% of UHC Fee Schedule,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,42.32,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,18.39,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,134.15,
"Blood test, thyroid stimulating hormone (TSH)",4087238,CDM,300,RC,84443,HCPCS,Outpatient,,,329.45,197.67,,59.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,230.62,70,,,percent of total billed charges,70% of total billed charges,247.09,75,,,percent of total billed charges,75% of total billed charges,30.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,263.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,350,,,Fee Schedule,350% of CMS OPPS Rate,17.13,102,,,Fee Schedule,102% of CMS OPPS Rate,252.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,148.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of UHC Fee Schedule,230.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,230,,,Fee Schedule,230% of CMS OPPS Rate,158.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,296.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,296.51,
"MALARIA SMEAR, BLD",4087239,CDM,306,RC,87207,HCPCS,Outpatient,,,63,37.8,,21.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,10.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.96,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,6.66,100,,,Fee Schedule,100% of UHC Fee Schedule,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,13.77,230,,,Fee Schedule,230% of CMS OPPS Rate,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,56.7,
"CONCENTRATION,MICRO",4087239,CDM,306,RC,87015,HCPCS,Outpatient,,,48.15,28.89,,23.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges,36.11,75,,,percent of total billed charges,75% of total billed charges,12.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.38,350,,,Fee Schedule,350% of CMS OPPS Rate,6.81,102,,,Fee Schedule,102% of CMS OPPS Rate,36.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of UHC Fee Schedule,33.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.36,230,,,Fee Schedule,230% of CMS OPPS Rate,23.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,43.34,
IGE SPECIFIC ALLERGINS,4087240,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE-IMMUNOGLOBULIN E,4087240,CDM,301,RC,82785,HCPCS,Outpatient,,,57.75,34.65,,58.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges,43.31,75,,,percent of total billed charges,75% of total billed charges,29.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.61,350,,,Fee Schedule,350% of CMS OPPS Rate,16.78,102,,,Fee Schedule,102% of CMS OPPS Rate,44.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,18.29,100,,,Fee Schedule,100% of UHC Fee Schedule,40.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,37.85,230,,,Fee Schedule,230% of CMS OPPS Rate,27.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,58.26,
BORDETELLA PERTUSSIS DFA,4087241,CDM,306,RC,87265,HCPCS,Outpatient,,,61,36.6,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,54.9,
IGE SPECIFIC ALLERGINS,4087242,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE SPECIFIC ALLERGINS,4087243,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE SPECIFIC ALLERGINS,4087244,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE SPECIFIC ALLERGINS,4087245,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE SPECIFIC ALLERGINS,4087246,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
MOLECULAR CYTOGENETICS,4087247,CDM,311,RC,88271,HCPCS,Outpatient,,,74.7,44.82,,75.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges,56.03,75,,,percent of total billed charges,75% of total billed charges,38.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.97,350,,,Fee Schedule,350% of CMS OPPS Rate,21.84,102,,,Fee Schedule,102% of CMS OPPS Rate,57.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,33.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,23.8,100,,,Fee Schedule,100% of UHC Fee Schedule,52.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,230,,,Fee Schedule,230% of CMS OPPS Rate,35.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,100,,,Fee Schedule,100% of CMS OPPS Rate,21.42,75.82,
MOLECULAR CYTOGENETICS INTERF,4087247,CDM,311,RC,88274,HCPCS,Outpatient,,,302.4,181.44,,150.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,87.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,211.68,70,,,percent of total billed charges,70% of total billed charges,226.8,75,,,percent of total billed charges,75% of total billed charges,76.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.33,350,,,Fee Schedule,350% of CMS OPPS Rate,43.22,102,,,Fee Schedule,102% of CMS OPPS Rate,231.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,136.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,100,,,Fee Schedule,100% of UHC Fee Schedule,211.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,97.47,230,,,Fee Schedule,230% of CMS OPPS Rate,145.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,272.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,272.16,
RENIN,4087248,CDM,301,RC,84244,HCPCS,Outpatient,,,366.3,219.78,,77.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.41,70,,,percent of total billed charges,70% of total billed charges,274.73,75,,,percent of total billed charges,75% of total billed charges,39.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,293.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.96,350,,,Fee Schedule,350% of CMS OPPS Rate,22.42,102,,,Fee Schedule,102% of CMS OPPS Rate,280.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,164.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,100,,,Fee Schedule,100% of UHC Fee Schedule,256.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,50.57,230,,,Fee Schedule,230% of CMS OPPS Rate,175.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,329.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,21.99,329.67,
ALDOSTERONE,4087248,CDM,301,RC,82088,HCPCS,Outpatient,,,504.9,302.94,,144.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,102.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges,378.68,75,,,percent of total billed charges,75% of total billed charges,73.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,403.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.62,350,,,Fee Schedule,350% of CMS OPPS Rate,41.56,102,,,Fee Schedule,102% of CMS OPPS Rate,386.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,227.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,45.28,100,,,Fee Schedule,100% of UHC Fee Schedule,353.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,93.72,230,,,Fee Schedule,230% of CMS OPPS Rate,242.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,454.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,100,,,Fee Schedule,100% of CMS OPPS Rate,40.75,454.41,
IGE SPECIFIC ALLERGINS,4087249,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
IGE SPECIFIC ALLERGINS,4087250,CDM,302,RC,86003,HCPCS,Outpatient,,,40.7,24.42,,18.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,9.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.27,350,,,Fee Schedule,350% of CMS OPPS Rate,5.32,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.8,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,100,,,Fee Schedule,100% of CMS OPPS Rate,5.22,36.63,
ALPHA 1 ANTITRYPSIN PHENOTYPR,4087251,CDM,301,RC,82104,HCPCS,Outpatient,,,210,126,,51.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.46,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,26.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.61,350,,,Fee Schedule,350% of CMS OPPS Rate,14.74,102,,,Fee Schedule,102% of CMS OPPS Rate,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of UHC Fee Schedule,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.25,230,,,Fee Schedule,230% of CMS OPPS Rate,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,189,
ALPHA-1 ANTITRYPSIN,4087251,CDM,301,RC,82103,HCPCS,Outpatient,,,206.8,124.08,,47.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.76,70,,,percent of total billed charges,70% of total billed charges,155.1,75,,,percent of total billed charges,75% of total billed charges,24.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.7,102,,,Fee Schedule,102% of CMS OPPS Rate,158.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,93.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,14.93,100,,,Fee Schedule,100% of UHC Fee Schedule,144.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,30.91,230,,,Fee Schedule,230% of CMS OPPS Rate,99.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,186.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,186.12,
BORRELIA B. ABS CONFIRM,4087252,CDM,302,RC,86617,HCPCS,Outpatient,,,54.45,32.67,,54.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.21,350,,,Fee Schedule,350% of CMS OPPS Rate,15.79,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,35.62,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,15.49,54.83,
HIV 2 IGG ABS (REFLEX),4087253,CDM,302,RC,86702,HCPCS,Outpatient,,,52.5,31.5,,47.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.75,70,,,percent of total billed charges,70% of total billed charges,39.38,75,,,percent of total billed charges,75% of total billed charges,24.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.32,350,,,Fee Schedule,350% of CMS OPPS Rate,13.79,102,,,Fee Schedule,102% of CMS OPPS Rate,40.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,23.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15.02,100,,,Fee Schedule,100% of UHC Fee Schedule,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,31.09,230,,,Fee Schedule,230% of CMS OPPS Rate,25.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,13.52,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,47.86,
HIV-1 STAT SCREEN,4087253,CDM,302,RC,86701,HCPCS,Outpatient,,,123.75,74.25,,31.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.89,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges,92.81,75,,,percent of total billed charges,75% of total billed charges,16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.11,350,,,Fee Schedule,350% of CMS OPPS Rate,9.06,102,,,Fee Schedule,102% of CMS OPPS Rate,94.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,9.87,100,,,Fee Schedule,100% of UHC Fee Schedule,86.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,20.44,230,,,Fee Schedule,230% of CMS OPPS Rate,59.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,100,,,Fee Schedule,100% of CMS OPPS Rate,8.89,111.38,
NEPHELOMETRY EA,4087254,CDM,300,RC,83883,HCPCS,Outpatient,,,41,24.6,,48.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,24.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.87,102,,,Fee Schedule,102% of CMS OPPS Rate,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of UHC Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,230,,,Fee Schedule,230% of CMS OPPS Rate,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,48.14,
Test to determine levels of immunoglobulins in the blood,4087254,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
"VIRUS ISOLATION, WITH ID",4087255,CDM,306,RC,87255,HCPCS,Outpatient,,,102,61.2,,119.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,60.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.51,350,,,Fee Schedule,350% of CMS OPPS Rate,34.53,102,,,Fee Schedule,102% of CMS OPPS Rate,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,37.63,100,,,Fee Schedule,100% of UHC Fee Schedule,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.87,230,,,Fee Schedule,230% of CMS OPPS Rate,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,100,,,Fee Schedule,100% of CMS OPPS Rate,33.86,119.86,
HERPES SIMPLEX 2 ABS,4087256,CDM,302,RC,86696,HCPCS,Outpatient,,,240.35,144.21,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges,180.26,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,183.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,108.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,115.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,216.32,
HERPES SIM.VIRUS 1 ABS,4087256,CDM,302,RC,86695,HCPCS,Outpatient,,,45.1,27.06,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
NEPHELOMETRY EA,4087257,CDM,300,RC,83883,HCPCS,Outpatient,,,41,24.6,,48.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,24.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.87,102,,,Fee Schedule,102% of CMS OPPS Rate,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of UHC Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,230,,,Fee Schedule,230% of CMS OPPS Rate,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,48.14,
CULTURE-VIRUS-MISC SPEC,4087261,CDM,306,RC,87252,HCPCS,Outpatient,,,229.5,137.7,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.65,70,,,percent of total billed charges,70% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,175.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,103.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,28.96,100,,,Fee Schedule,100% of UHC Fee Schedule,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,110.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,206.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,206.55,
VIRUS ISOLATION SHELL TECHNIQUE,4087261,CDM,300,RC,87254,HCPCS,Outpatient,,,247.1,148.26,,69.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,172.97,70,,,percent of total billed charges,70% of total billed charges,185.33,75,,,percent of total billed charges,75% of total billed charges,35.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,197.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.46,350,,,Fee Schedule,350% of CMS OPPS Rate,19.95,102,,,Fee Schedule,102% of CMS OPPS Rate,189.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,111.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,21.74,100,,,Fee Schedule,100% of UHC Fee Schedule,172.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,44.98,230,,,Fee Schedule,230% of CMS OPPS Rate,118.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,222.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,222.39,
BUPRENOPHINE,4087262,CDM,301,RC,80348,HCPCS,Outpatient,,,200,120,,,,,,Other,Not Separately reimbursable,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,180,
OPIOIDS AND OPIATE ANALOGS 1 -2C,4087262,CDM,300,RC,80362,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,144,
IMMUNOASSAY ANALYTE,4087263,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
FLORESCENT CHEM ABS,4087263,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
CRP (C-REACT PROT),4087263,CDM,302,RC,86140,HCPCS,Outpatient,,,78.65,47.19,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges,58.99,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,62.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,60.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,35.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,55.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,37.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,70.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,70.79,
UNLISTED MOLECULAR PROCEDURE,4087263,CDM,300,RC,81479,HCPCS,Outpatient,,,402,241.2,,,,,,Other,Not Separately reimbursable,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,281.4,70,,,percent of total billed charges,70% of total billed charges,301.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.99,361.8,
CHEMILUMINESCENT ASSAY,4087263,CDM,301,RC,82397,HCPCS,Outpatient,,,85.95,51.57,,49.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.54,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.17,70,,,percent of total billed charges,70% of total billed charges,64.46,75,,,percent of total billed charges,75% of total billed charges,25.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.42,350,,,Fee Schedule,350% of CMS OPPS Rate,14.4,102,,,Fee Schedule,102% of CMS OPPS Rate,65.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,15.69,100,,,Fee Schedule,100% of UHC Fee Schedule,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,32.47,230,,,Fee Schedule,230% of CMS OPPS Rate,41.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,14.12,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,77.36,
"INFECTIOUS AGENT AG, GIARDIA",4087269,CDM,309,RC,87269,HCPCS,Outpatient,,,278,166.8,,48.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,194.6,70,,,percent of total billed charges,70% of total billed charges,208.5,75,,,percent of total billed charges,75% of total billed charges,24.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,350,,,Fee Schedule,350% of CMS OPPS Rate,13.88,102,,,Fee Schedule,102% of CMS OPPS Rate,212.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,125.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,194.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,31.3,230,,,Fee Schedule,230% of CMS OPPS Rate,133.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,250.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,250.2,
CMV BY DFA,4087271,CDM,306,RC,87271,HCPCS,Outpatient,,,49.95,29.97,,47.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,24.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.97,350,,,Fee Schedule,350% of CMS OPPS Rate,13.68,102,,,Fee Schedule,102% of CMS OPPS Rate,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,230,,,Fee Schedule,230% of CMS OPPS Rate,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,47.5,
"INFECTIOUS AGENT AG, CRYPTOSPOR",4087272,CDM,309,RC,87272,HCPCS,Outpatient,,,250.2,150.12,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,175.14,70,,,percent of total billed charges,70% of total billed charges,187.65,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,200.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,191.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,112.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,175.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,120.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,225.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,225.18,
INFLUENZA A ANTIGEN,4087273,CDM,306,RC,87276,HCPCS,Outpatient,,,33,19.8,,56.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.1,70,,,percent of total billed charges,70% of total billed charges,24.75,75,,,percent of total billed charges,75% of total billed charges,28.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.24,350,,,Fee Schedule,350% of CMS OPPS Rate,16.39,102,,,Fee Schedule,102% of CMS OPPS Rate,25.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of UHC Fee Schedule,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33,230,,,Fee Schedule,230% of CMS OPPS Rate,15.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,56.88,
HERPES SIMPLES L AG,4087274,CDM,306,RC,87274,HCPCS,Outpatient,,,33,19.8,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.1,70,,,percent of total billed charges,70% of total billed charges,24.75,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,25.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,15.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,42.4,
"INFLUENZA B,AG BY IF",4087275,CDM,300,RC,87275,HCPCS,Outpatient,,,32.5,19.5,,43.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,22.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,350,,,Fee Schedule,350% of CMS OPPS Rate,12.49,102,,,Fee Schedule,102% of CMS OPPS Rate,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,230,,,Fee Schedule,230% of CMS OPPS Rate,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,43.36,
IMMUNOASSAY ANALYTE,4087277,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
ADALIMUMAB,4087277,CDM,300,RC,80145,HCPCS,Outpatient,,,626,375.6,,136.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,313,50,,,percent of total billed charges,pays at 50% of total billed charges,438.2,70,,,percent of total billed charges,70% of total billed charges,469.5,75,,,percent of total billed charges,75% of total billed charges,69.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.99,350,,,Fee Schedule,350% of CMS OPPS Rate,39.34,102,,,Fee Schedule,102% of CMS OPPS Rate,478.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,281.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,375.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.71,100,,,Fee Schedule,100% of UHC Fee Schedule,438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,88.71,230,,,Fee Schedule,230% of CMS OPPS Rate,300.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,563.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,29.86,563.4,
INFECTIOUS A AG BY IMMUNOFLUORSCNT,4087278,CDM,309,RC,87278,HCPCS,Outpatient,,,224,134.4,,55.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,156.8,70,,,percent of total billed charges,70% of total billed charges,168,75,,,percent of total billed charges,75% of total billed charges,28.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,179.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.6,350,,,Fee Schedule,350% of CMS OPPS Rate,15.91,102,,,Fee Schedule,102% of CMS OPPS Rate,171.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,100.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.04,100,,,Fee Schedule,100% of UHC Fee Schedule,156.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,35.88,230,,,Fee Schedule,230% of CMS OPPS Rate,107.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,201.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14.04,201.6,
"PARAINFLUENZA,AG BY IF",4087279,CDM,300,RC,87279,HCPCS,Outpatient,,,32.5,19.5,,58.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,29.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.5,350,,,Fee Schedule,350% of CMS OPPS Rate,16.75,102,,,Fee Schedule,102% of CMS OPPS Rate,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of UHC Fee Schedule,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,32.5,230,,,Fee Schedule,230% of CMS OPPS Rate,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,16.43,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,58.16,
"RSV AG, BY IF",4087280,CDM,300,RC,87280,HCPCS,Outpatient,,,32.5,19.5,,47.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22.75,70,,,percent of total billed charges,70% of total billed charges,24.38,75,,,percent of total billed charges,75% of total billed charges,24.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.97,350,,,Fee Schedule,350% of CMS OPPS Rate,13.68,102,,,Fee Schedule,102% of CMS OPPS Rate,24.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,14.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,22.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,30.86,230,,,Fee Schedule,230% of CMS OPPS Rate,15.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,29.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.42,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,47.5,
INFECTIOUS AGENT AG PNEUMOCYSTIS C.,4087281,CDM,309,RC,87281,HCPCS,Outpatient,,,109.2,65.52,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.44,70,,,percent of total billed charges,70% of total billed charges,81.9,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,87.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,83.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,49.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,76.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,52.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,98.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,98.28,
"ANTI-THYROGLOBULIN AB,SER",4087290,CDM,302,RC,86800,HCPCS,Outpatient,,,95.7,57.42,,56.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.91,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,28.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.68,350,,,Fee Schedule,350% of CMS OPPS Rate,16.22,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,36.59,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,86.13,
MICROSOMAL AB,4087305,CDM,302,RC,86376,HCPCS,Outpatient,,,95.7,57.42,,51.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,26.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.92,350,,,Fee Schedule,350% of CMS OPPS Rate,14.84,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,86.13,
ANTI-MUMPS AB,4087307,CDM,302,RC,86735,HCPCS,Outpatient,,,50.6,30.36,,46.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,23.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.67,350,,,Fee Schedule,350% of CMS OPPS Rate,13.31,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14.5,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,30.01,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.05,46.19,
"TOXOPLASMA, IGM ABS",4087308,CDM,302,RC,86778,HCPCS,Outpatient,,,66.15,39.69,,51.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.43,350,,,Fee Schedule,350% of CMS OPPS Rate,14.69,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,33.14,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,59.54,
TOXOPLASMA (TOXO AB),4087308,CDM,302,RC,86777,HCPCS,Outpatient,,,66.15,39.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.81,59.54,
ANTIBODY ID LEUKOCYTE ABS,4087309,CDM,302,RC,86021,HCPCS,Outpatient,,,54.45,32.67,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
FLORESCENT CHEM ABS,4087309,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
IMMUNOASSAY ANALYTE,4087309,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
SACCHAROMYCES CEREVIS.ABS,4087309,CDM,300,RC,86671,HCPCS,Outpatient,,,128.15,76.89,,43.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges,96.11,75,,,percent of total billed charges,75% of total billed charges,22.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,350,,,Fee Schedule,350% of CMS OPPS Rate,12.49,102,,,Fee Schedule,102% of CMS OPPS Rate,98.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,57.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of UHC Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,230,,,Fee Schedule,230% of CMS OPPS Rate,61.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,115.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,115.34,
"BACTERIUM ABS,IMMUNOASSAY",4087309,CDM,300,RC,86609,HCPCS,Outpatient,,,39,23.4,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,45.59,
SM(SMITH) IGG ABS,4087312,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
FLORESCENT CHEM ABS,4087312,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
ANA(REFLEX TITER),4087312,CDM,302,RC,86038,HCPCS,Outpatient,,,228.8,137.28,,42.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,21.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.31,350,,,Fee Schedule,350% of CMS OPPS Rate,12.33,102,,,Fee Schedule,102% of CMS OPPS Rate,175.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,13.43,100,,,Fee Schedule,100% of UHC Fee Schedule,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,230,,,Fee Schedule,230% of CMS OPPS Rate,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,205.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,100,,,Fee Schedule,100% of CMS OPPS Rate,12.09,205.92,
RA QUANTITATIVE,4087312,CDM,302,RC,86431,HCPCS,Outpatient,,,88,52.8,,20.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,10.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.84,350,,,Fee Schedule,350% of CMS OPPS Rate,5.78,102,,,Fee Schedule,102% of CMS OPPS Rate,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,100,,,Fee Schedule,100% of UHC Fee Schedule,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13.04,230,,,Fee Schedule,230% of CMS OPPS Rate,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5.67,79.2,
FLORESCENT CHEM ABS,4087313,CDM,302,RC,86255,HCPCS,Outpatient,,,193.05,115.83,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,173.75,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4087313,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
PROTEIN TOTAL URINE,4087314,CDM,301,RC,84156,HCPCS,Outpatient,,,50.85,30.51,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges,38.14,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,38.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,35.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,24.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,45.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,45.77,
PROTEIN ELECT.URINE RAND,4087314,CDM,300,RC,84166,HCPCS,Outpatient,,,261,156.6,,63.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges,195.75,75,,,percent of total billed charges,75% of total billed charges,32.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,350,,,Fee Schedule,350% of CMS OPPS Rate,18.18,102,,,Fee Schedule,102% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,100,,,Fee Schedule,100% of UHC Fee Schedule,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,41,230,,,Fee Schedule,230% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,100,,,Fee Schedule,100% of CMS OPPS Rate,17.82,234.9,
PROTEIN ELECTROPHORESIS,4087316,CDM,300,RC,84165,HCPCS,Outpatient,,,173.7,104.22,,38.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges,130.28,75,,,percent of total billed charges,75% of total billed charges,19.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,138.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.59,350,,,Fee Schedule,350% of CMS OPPS Rate,10.95,102,,,Fee Schedule,102% of CMS OPPS Rate,132.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of UHC Fee Schedule,121.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.7,230,,,Fee Schedule,230% of CMS OPPS Rate,83.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,156.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,100,,,Fee Schedule,100% of CMS OPPS Rate,10.74,156.33,
PROTEIN SERUM,4087316,CDM,301,RC,84155,HCPCS,Outpatient,,,85.25,51.15,,12.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.67,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges,63.94,75,,,percent of total billed charges,75% of total billed charges,6.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.84,350,,,Fee Schedule,350% of CMS OPPS Rate,3.74,102,,,Fee Schedule,102% of CMS OPPS Rate,65.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,38.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4.08,100,,,Fee Schedule,100% of UHC Fee Schedule,59.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,8.44,230,,,Fee Schedule,230% of CMS OPPS Rate,40.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,76.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3.67,76.73,
PHOSPHOROUS URINE 24 HR,4087317,CDM,301,RC,84105,HCPCS,Outpatient,,,101,60.6,,20.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70.7,70,,,percent of total billed charges,70% of total billed charges,75.75,75,,,percent of total billed charges,75% of total billed charges,10.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,350,,,Fee Schedule,350% of CMS OPPS Rate,5.89,102,,,Fee Schedule,102% of CMS OPPS Rate,77.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,70.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,230,,,Fee Schedule,230% of CMS OPPS Rate,48.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,90.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,90.9,
"OXALATE, URINE",4087317,CDM,301,RC,83945,HCPCS,Outpatient,,,194.15,116.49,,51.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.91,70,,,percent of total billed charges,70% of total billed charges,145.61,75,,,percent of total billed charges,75% of total billed charges,26.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,155.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.57,350,,,Fee Schedule,350% of CMS OPPS Rate,14.73,102,,,Fee Schedule,102% of CMS OPPS Rate,148.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,87.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,100,,,Fee Schedule,100% of UHC Fee Schedule,135.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,33.23,230,,,Fee Schedule,230% of CMS OPPS Rate,93.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,174.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14.3,174.74,
CITRATE-UR-24 HR,4087317,CDM,301,RC,82507,HCPCS,Outpatient,,,301.4,180.84,,98.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,210.98,70,,,percent of total billed charges,70% of total billed charges,226.05,75,,,percent of total billed charges,75% of total billed charges,50.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.3,350,,,Fee Schedule,350% of CMS OPPS Rate,28.35,102,,,Fee Schedule,102% of CMS OPPS Rate,230.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,135.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,100,,,Fee Schedule,100% of UHC Fee Schedule,210.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,63.94,230,,,Fee Schedule,230% of CMS OPPS Rate,144.67,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,271.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,100,,,Fee Schedule,100% of CMS OPPS Rate,27.8,271.26,
CHLORIDE URINE,4087317,CDM,301,RC,82436,HCPCS,Outpatient,,,88.65,53.19,,20.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges,66.49,75,,,percent of total billed charges,75% of total billed charges,10.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,70.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.12,350,,,Fee Schedule,350% of CMS OPPS Rate,5.86,102,,,Fee Schedule,102% of CMS OPPS Rate,67.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,39.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.59,100,,,Fee Schedule,100% of UHC Fee Schedule,62.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,230,,,Fee Schedule,230% of CMS OPPS Rate,42.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,79.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5.59,79.79,
UREA NITROGEN URINE,4087317,CDM,301,RC,84540,HCPCS,Outpatient,,,69.75,41.85,,19.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.51,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,10,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.45,350,,,Fee Schedule,350% of CMS OPPS Rate,5.67,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,12.78,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.51,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,62.78,
Test to measure creatinine in the urine,4087317,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
OSMOLALITY URINE,4087317,CDM,301,RC,83935,HCPCS,Outpatient,,,52.2,31.32,,24.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.82,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,12.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.87,350,,,Fee Schedule,350% of CMS OPPS Rate,6.95,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,46.98,
AMMONIA PLASMA,4087317,CDM,301,RC,82140,HCPCS,Outpatient,,,105.75,63.45,,51.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.03,70,,,percent of total billed charges,70% of total billed charges,79.31,75,,,percent of total billed charges,75% of total billed charges,26.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.99,350,,,Fee Schedule,350% of CMS OPPS Rate,14.86,102,,,Fee Schedule,102% of CMS OPPS Rate,80.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,16.19,100,,,Fee Schedule,100% of UHC Fee Schedule,74.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,33.51,230,,,Fee Schedule,230% of CMS OPPS Rate,50.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,95.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,100,,,Fee Schedule,100% of CMS OPPS Rate,14.57,95.18,
URIC ACID URINE,4087317,CDM,301,RC,84560,HCPCS,Outpatient,,,124.65,74.79,,17.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,9.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.78,350,,,Fee Schedule,350% of CMS OPPS Rate,5.18,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,11.68,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,100,,,Fee Schedule,100% of CMS OPPS Rate,5.08,112.19,
SODIUM URINE,4087317,CDM,301,RC,84300,HCPCS,Outpatient,,,52.2,31.32,,17.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,9.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,350,,,Fee Schedule,350% of CMS OPPS Rate,5.16,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.4,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11.63,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,100,,,Fee Schedule,100% of CMS OPPS Rate,5.05,46.98,
POTASSIUM URINE,4087317,CDM,301,RC,84133,HCPCS,Outpatient,,,52.2,31.32,,16.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,350,,,Fee Schedule,350% of CMS OPPS Rate,4.82,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.79,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,10.87,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,100,,,Fee Schedule,100% of CMS OPPS Rate,4.73,46.98,
"PH, MISC FLUID",4087317,CDM,301,RC,83986,HCPCS,Outpatient,,,44.55,26.73,,12.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.19,70,,,percent of total billed charges,70% of total billed charges,33.41,75,,,percent of total billed charges,75% of total billed charges,6.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,350,,,Fee Schedule,350% of CMS OPPS Rate,3.65,102,,,Fee Schedule,102% of CMS OPPS Rate,34.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of UHC Fee Schedule,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,230,,,Fee Schedule,230% of CMS OPPS Rate,21.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,40.1,
MAGNESIUM ASSAY,4087317,CDM,301,RC,83735,HCPCS,Outpatient,,,111.6,66.96,,23.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,12.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.45,350,,,Fee Schedule,350% of CMS OPPS Rate,6.83,102,,,Fee Schedule,102% of CMS OPPS Rate,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,7.44,100,,,Fee Schedule,100% of UHC Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,15.41,230,,,Fee Schedule,230% of CMS OPPS Rate,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100.44,
CALCIUM URINE,4087317,CDM,301,RC,82340,HCPCS,Outpatient,,,98.1,58.86,,21.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges,73.58,75,,,percent of total billed charges,75% of total billed charges,10.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.1,350,,,Fee Schedule,350% of CMS OPPS Rate,6.15,102,,,Fee Schedule,102% of CMS OPPS Rate,75.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of UHC Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.86,230,,,Fee Schedule,230% of CMS OPPS Rate,47.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6.03,88.29,
SULFATE URINE,4087317,CDM,301,RC,84392,HCPCS,Outpatient,,,16,9.6,,19.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,11.2,70,,,percent of total billed charges,70% of total billed charges,12,75,,,percent of total billed charges,75% of total billed charges,9.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.21,350,,,Fee Schedule,350% of CMS OPPS Rate,5.59,102,,,Fee Schedule,102% of CMS OPPS Rate,12.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,100,,,Fee Schedule,100% of UHC Fee Schedule,11.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,230,,,Fee Schedule,230% of CMS OPPS Rate,7.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,14.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.49,100,,,Fee Schedule,100% of CMS OPPS Rate,5.27,19.43,
SM(SMITH) IGG ABS,4087318,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4087318,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
ANTI-PLATELET ANTIBODY,4087319,CDM,302,RC,86022,HCPCS,Outpatient,,,94.5,56.7,,65.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.37,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges,70.88,75,,,percent of total billed charges,75% of total billed charges,33.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,75.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.29,350,,,Fee Schedule,350% of CMS OPPS Rate,18.73,102,,,Fee Schedule,102% of CMS OPPS Rate,72.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,20.41,100,,,Fee Schedule,100% of UHC Fee Schedule,66.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,42.25,230,,,Fee Schedule,230% of CMS OPPS Rate,45.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,85.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,100,,,Fee Schedule,100% of CMS OPPS Rate,18.37,85.05,
ANTIBODY ID LEUKOCYTE ABS,4087320,CDM,302,RC,86021,HCPCS,Outpatient,,,54.45,32.67,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges,40.84,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,41.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,38.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,26.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,49.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
SACCHAROMYCES CEREVIS.ABS,4087320,CDM,300,RC,86671,HCPCS,Outpatient,,,128.15,76.89,,43.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges,96.11,75,,,percent of total billed charges,75% of total billed charges,22.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.87,350,,,Fee Schedule,350% of CMS OPPS Rate,12.49,102,,,Fee Schedule,102% of CMS OPPS Rate,98.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,57.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,13.62,100,,,Fee Schedule,100% of UHC Fee Schedule,89.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,28.17,230,,,Fee Schedule,230% of CMS OPPS Rate,61.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,115.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.25,115.34,
GGT GAMMA GLUTAM TRNSFRS SERUM,4087321,CDM,301,RC,82977,HCPCS,Outpatient,,,152.1,91.26,,25.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,12.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.2,350,,,Fee Schedule,350% of CMS OPPS Rate,7.34,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,8,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,16.56,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,100,,,Fee Schedule,100% of CMS OPPS Rate,7.2,136.89,
Blood test to evaluate liver function,4087321,CDM,301,RC,84460,HCPCS,Outpatient,,,253,151.8,,18.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges,189.75,75,,,percent of total billed charges,75% of total billed charges,9.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,202.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.55,350,,,Fee Schedule,350% of CMS OPPS Rate,5.4,102,,,Fee Schedule,102% of CMS OPPS Rate,193.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,113.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.89,100,,,Fee Schedule,100% of UHC Fee Schedule,177.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.19,230,,,Fee Schedule,230% of CMS OPPS Rate,121.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,227.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,227.7,
"HAPTOGLOBIN,SERUM",4087321,CDM,301,RC,83010,HCPCS,Outpatient,,,103.95,62.37,,44.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges,77.96,75,,,percent of total billed charges,75% of total billed charges,22.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.03,350,,,Fee Schedule,350% of CMS OPPS Rate,12.83,102,,,Fee Schedule,102% of CMS OPPS Rate,79.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,13.98,100,,,Fee Schedule,100% of UHC Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,28.93,230,,,Fee Schedule,230% of CMS OPPS Rate,49.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,93.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.58,93.56,
BILIRUBIN TOTAL,4087321,CDM,301,RC,82247,HCPCS,Outpatient,,,113.4,68.04,,17.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges,85.05,75,,,percent of total billed charges,75% of total billed charges,9.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.56,350,,,Fee Schedule,350% of CMS OPPS Rate,5.12,102,,,Fee Schedule,102% of CMS OPPS Rate,86.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,51.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.57,100,,,Fee Schedule,100% of UHC Fee Schedule,79.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,230,,,Fee Schedule,230% of CMS OPPS Rate,54.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.84,102.06,
NEPHELOMETRY EA,4087321,CDM,300,RC,83883,HCPCS,Outpatient,,,41,24.6,,48.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,24.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.87,102,,,Fee Schedule,102% of CMS OPPS Rate,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of UHC Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,230,,,Fee Schedule,230% of CMS OPPS Rate,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,48.14,
"ORGANIC ACID SINGLE, QUAN",4087322,CDM,301,RC,83921,HCPCS,Outpatient,,,92.4,55.44,,75.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.68,70,,,percent of total billed charges,70% of total billed charges,69.3,75,,,percent of total billed charges,75% of total billed charges,38.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.23,350,,,Fee Schedule,350% of CMS OPPS Rate,21.63,102,,,Fee Schedule,102% of CMS OPPS Rate,70.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,41.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,100,,,Fee Schedule,100% of UHC Fee Schedule,64.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,48.78,230,,,Fee Schedule,230% of CMS OPPS Rate,44.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,83.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,21.21,100,,,Fee Schedule,100% of CMS OPPS Rate,19.09,83.16,
Test to measure creatinine in the urine,4087322,CDM,301,RC,82570,HCPCS,Outpatient,,,62.55,37.53,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges,46.91,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,47.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,43.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,30.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,56.3,
ALBUMIN BLOOD,4087323,CDM,301,RC,82040,HCPCS,Outpatient,,,90.9,54.54,,17.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges,68.18,75,,,percent of total billed charges,75% of total billed charges,8.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.32,350,,,Fee Schedule,350% of CMS OPPS Rate,5.04,102,,,Fee Schedule,102% of CMS OPPS Rate,69.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.5,100,,,Fee Schedule,100% of UHC Fee Schedule,63.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11.38,230,,,Fee Schedule,230% of CMS OPPS Rate,43.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,81.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,100,,,Fee Schedule,100% of CMS OPPS Rate,4.95,81.81,
Test to determine levels of immunoglobulins in the blood,4087323,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
SM(SMITH) IGG ABS,4087324,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
ANTI-DS DNA,4087324,CDM,302,RC,86225,HCPCS,Outpatient,,,47.3,28.38,,48.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges,35.48,75,,,percent of total billed charges,75% of total billed charges,24.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.09,350,,,Fee Schedule,350% of CMS OPPS Rate,14.01,102,,,Fee Schedule,102% of CMS OPPS Rate,36.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,21.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.27,100,,,Fee Schedule,100% of UHC Fee Schedule,33.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,230,,,Fee Schedule,230% of CMS OPPS Rate,22.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.74,48.63,
SM(SMITH) IGG ABS,4087325,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
SM(SMITH) IGG ABS,4087326,CDM,302,RC,86235,HCPCS,Outpatient,,,119.9,71.94,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,107.91,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4087326,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
SAR COVID-19 ANTIBODY,4087327,CDM,300,RC,86769,HCPCS,Outpatient,,,144,86.4,,149.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72,50,,,percent of total billed charges,pays at 50% of total billed charges,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,75.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.45,350,,,Fee Schedule,350% of CMS OPPS Rate,42.97,102,,,Fee Schedule,102% of CMS OPPS Rate,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,96.89,230,,,Fee Schedule,230% of CMS OPPS Rate,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,31.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,42.13,100,,,Fee Schedule,100% of CMS OPPS Rate,31.6,149.14,
COXSACKIE ENTEROVIRUS EA,4087328,CDM,302,RC,86658,HCPCS,Outpatient,,,74.5,44.7,,46.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.03,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.15,70,,,percent of total billed charges,70% of total billed charges,55.88,75,,,percent of total billed charges,75% of total billed charges,23.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.29,102,,,Fee Schedule,102% of CMS OPPS Rate,56.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,33.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,14.47,100,,,Fee Schedule,100% of UHC Fee Schedule,52.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,29.96,230,,,Fee Schedule,230% of CMS OPPS Rate,35.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,100,,,Fee Schedule,100% of CMS OPPS Rate,13.03,67.05,
IMMUNOASSAY ANALYTE,4087329,CDM,300,RC,83520,HCPCS,Outpatient,,,165,99,,61.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,31.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.44,350,,,Fee Schedule,350% of CMS OPPS Rate,17.61,102,,,Fee Schedule,102% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,15.54,100,,,Fee Schedule,100% of UHC Fee Schedule,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.72,230,,,Fee Schedule,230% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.84,148.5,
INFIXIMAB,4087329,CDM,300,RC,80230,HCPCS,Outpatient,,,404,242.4,,136.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202,50,,,percent of total billed charges,pays at 50% of total billed charges,282.8,70,,,percent of total billed charges,70% of total billed charges,303,75,,,percent of total billed charges,75% of total billed charges,69.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.99,350,,,Fee Schedule,350% of CMS OPPS Rate,39.34,102,,,Fee Schedule,102% of CMS OPPS Rate,309.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,181.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.71,100,,,Fee Schedule,100% of UHC Fee Schedule,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,88.71,230,,,Fee Schedule,230% of CMS OPPS Rate,193.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,363.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,29.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,38.57,100,,,Fee Schedule,100% of CMS OPPS Rate,29.86,363.6,
SAR COVID-19,4087335,CDM,300,RC,U0002,HCPCS,Outpatient,,,714,428.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,100,,,Fee Schedule,100% of UHC Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,642.6,
ENTAMOEBA HISTOLYTICA AG,4087337,CDM,300,RC,87337,HCPCS,Outpatient,,,64.9,38.94,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.43,70,,,percent of total billed charges,70% of total billed charges,48.68,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,49.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,29.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,45.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,31.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,58.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,58.41,
SAR COVID-19 HIGH THROUGHPUT,4087339,CDM,300,RC,U0003,HCPCS,Outpatient,,,714,428.4,,,,,,Other,Not Separately reimbursable,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357,50,,,percent of total billed charges,pays at 50% of total billed charges,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,357,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.88,642.6,
HEPATITIS B SURFACE AG IA,4087341,CDM,306,RC,87341,HCPCS,Outpatient,,,50,30,,36.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,18.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.15,350,,,Fee Schedule,350% of CMS OPPS Rate,10.53,102,,,Fee Schedule,102% of CMS OPPS Rate,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.48,100,,,Fee Schedule,100% of UHC Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,23.75,230,,,Fee Schedule,230% of CMS OPPS Rate,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,45,
FEBRILE AGGL (FRANC TULR),4087362,CDM,302,RC,86668,HCPCS,Outpatient,,,87,52.2,,50.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.42,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,25.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.56,350,,,Fee Schedule,350% of CMS OPPS Rate,14.44,102,,,Fee Schedule,102% of CMS OPPS Rate,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.74,100,,,Fee Schedule,100% of UHC Fee Schedule,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,230,,,Fee Schedule,230% of CMS OPPS Rate,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.42,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,14.16,100,,,Fee Schedule,100% of CMS OPPS Rate,12.74,78.3,
SALMONELLA ANTIBODY,4087368,CDM,302,RC,86768,HCPCS,Outpatient,,,37,22.2,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.9,70,,,percent of total billed charges,70% of total billed charges,27.75,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,28.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,16.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,25.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,17.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,33.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
HEPATITIS DELTA AG IEA,4087380,CDM,306,RC,87380,HCPCS,Outpatient,,,166.1,99.66,,64.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,116.27,70,,,percent of total billed charges,70% of total billed charges,124.58,75,,,percent of total billed charges,75% of total billed charges,33.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.26,350,,,Fee Schedule,350% of CMS OPPS Rate,18.72,102,,,Fee Schedule,102% of CMS OPPS Rate,127.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,74.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.23,100,,,Fee Schedule,100% of UHC Fee Schedule,116.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,42.22,230,,,Fee Schedule,230% of CMS OPPS Rate,79.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,149.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,100,,,Fee Schedule,100% of CMS OPPS Rate,17.21,149.49,
Test for HIV,4087389,CDM,302,RC,87389,HCPCS,Outpatient,,,200,120,,85.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,43.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.28,350,,,Fee Schedule,350% of CMS OPPS Rate,24.56,102,,,Fee Schedule,102% of CMS OPPS Rate,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,26.76,100,,,Fee Schedule,100% of UHC Fee Schedule,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,55.38,230,,,Fee Schedule,230% of CMS OPPS Rate,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,100,,,Fee Schedule,100% of CMS OPPS Rate,24.08,180,
HIV-1 ANTIGEN,4087390,CDM,306,RC,87390,HCPCS,Outpatient,,,182,109.2,,85.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,24.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,24.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.4,70,,,percent of total billed charges,70% of total billed charges,136.5,75,,,percent of total billed charges,75% of total billed charges,43.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.21,350,,,Fee Schedule,350% of CMS OPPS Rate,24.54,102,,,Fee Schedule,102% of CMS OPPS Rate,139.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,81.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,21.65,100,,,Fee Schedule,100% of UHC Fee Schedule,127.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,55.33,230,,,Fee Schedule,230% of CMS OPPS Rate,87.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,163.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,23.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,100,,,Fee Schedule,100% of CMS OPPS Rate,21.65,163.8,
SHIGA-LIKE TOXIN AG IA,4087427,CDM,306,RC,87427,HCPCS,Outpatient,,,108.24,64.94,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges,81.18,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,82.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,48.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,51.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,97.42,
INFECTIOUS AGENT BARTONELLA DNA PRBE,4087471,CDM,306,RC,87471,HCPCS,Outpatient,,,238.8,143.28,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges,179.1,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,214.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,214.92,
CANDIDA  SPECIES DNA DIR PROBE,4087480,CDM,306,RC,87480,HCPCS,Outpatient,,,136.6,81.96,,70.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,95.62,70,,,percent of total billed charges,70% of total billed charges,102.45,75,,,percent of total billed charges,75% of total billed charges,36.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.17,350,,,Fee Schedule,350% of CMS OPPS Rate,20.45,102,,,Fee Schedule,102% of CMS OPPS Rate,104.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,61.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of UHC Fee Schedule,95.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.11,230,,,Fee Schedule,230% of CMS OPPS Rate,65.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,122.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,122.94,
CANDIDA  SPECIES AMPLFD PROBE TECH,4087481,CDM,306,RC,87481,HCPCS,Outpatient,,,240.7,144.42,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.49,70,,,percent of total billed charges,70% of total billed charges,180.53,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,184.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,108.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,168.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,115.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,216.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,216.63,
"CANDIDA SPECIES DNA, RNA  AGENT",4087482,CDM,300,RC,87482,HCPCS,Outpatient,,,278,166.8,,197.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,55.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,55.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,113.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,194.6,70,,,percent of total billed charges,70% of total billed charges,208.5,75,,,percent of total billed charges,75% of total billed charges,100.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.09,350,,,Fee Schedule,350% of CMS OPPS Rate,56.85,102,,,Fee Schedule,102% of CMS OPPS Rate,212.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,125.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,50.17,100,,,Fee Schedule,100% of UHC Fee Schedule,194.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,128.2,230,,,Fee Schedule,230% of CMS OPPS Rate,133.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,250.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,55.74,100,,,Fee Schedule,100% of CMS OPPS Rate,24.93,250.2,
INFECTIOUS AGENT BY DNA CNS PATHOGENS,4087483,CDM,300,RC,87483,HCPCS,Outpatient,,,1931.5,1158.9,,1475.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,1352.05,70,,,percent of total billed charges,70% of total billed charges,1448.63,75,,,percent of total billed charges,75% of total billed charges,750.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1545.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1458.73,350,,,Fee Schedule,350% of CMS OPPS Rate,425.11,102,,,Fee Schedule,102% of CMS OPPS Rate,1477.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,869.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1352.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1158.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,463.1,100,,,Fee Schedule,100% of UHC Fee Schedule,1352.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,958.59,230,,,Fee Schedule,230% of CMS OPPS Rate,927.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1738.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,43.58,1738.35,
CHLAMYDIA PNEUM PROBE,4087486,CDM,300,RC,87486,HCPCS,Outpatient,,,239,143.4,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,215.1,
Test that detects Chlamydia,4087491,CDM,300,RC,87491,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
INFECTIOUS AGENT DNA CLOSTRIDIUM D,4087493,CDM,300,RC,87493,HCPCS,Outpatient,,,252,151.2,,131.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,67.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,130.44,350,,,Fee Schedule,350% of CMS OPPS Rate,38.01,102,,,Fee Schedule,102% of CMS OPPS Rate,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,85.72,230,,,Fee Schedule,230% of CMS OPPS Rate,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.27,226.8,
CMV DNA DETECTOR,4087496,CDM,300,RC,87496,HCPCS,Outpatient,,,227.7,136.62,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,159.39,70,,,percent of total billed charges,70% of total billed charges,170.78,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,182.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,174.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,102.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,159.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,109.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,204.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,204.93,
CYTOMEGALOVIRUS NA QUAN,4087497,CDM,306,RC,87497,HCPCS,Outpatient,,,138.6,83.16,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges,103.95,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,106.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,97.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,66.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,151.65,
ENTEROVIRUS DNA AMP PROBE,4087498,CDM,306,RC,87498,HCPCS,Outpatient,,,323.1,193.86,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,226.17,70,,,percent of total billed charges,70% of total billed charges,242.33,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,258.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,247.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,145.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,226.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,155.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,290.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,290.79,
MICROSOMAL AB,4087501,CDM,302,RC,86376,HCPCS,Outpatient,,,95.7,57.42,,51.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,26.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.92,350,,,Fee Schedule,350% of CMS OPPS Rate,14.84,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,86.13,
"ANTI-THYROGLOBULIN AB,SER",4087501,CDM,302,RC,86800,HCPCS,Outpatient,,,95.7,57.42,,56.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.91,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges,71.78,75,,,percent of total billed charges,75% of total billed charges,28.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.68,350,,,Fee Schedule,350% of CMS OPPS Rate,16.22,102,,,Fee Schedule,102% of CMS OPPS Rate,73.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,43.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,17.68,100,,,Fee Schedule,100% of UHC Fee Schedule,66.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,36.59,230,,,Fee Schedule,230% of CMS OPPS Rate,45.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,100,,,Fee Schedule,100% of CMS OPPS Rate,15.91,86.13,
TISSUE TRANSGLUTAMINASE IG,4087503,CDM,300,RC,86364,HCPCS,Outpatient,,,106,63.6,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53,50,,,percent of total billed charges,pays at 50% of total billed charges,74.2,70,,,percent of total billed charges,70% of total billed charges,79.5,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,81.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,47.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,74.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,50.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8.65,95.4,
Test to determine levels of immunoglobulins in the blood,4087503,CDM,300,RC,82784,HCPCS,Outpatient,,,28,16.8,,32.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges,21,75,,,percent of total billed charges,75% of total billed charges,16.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.55,350,,,Fee Schedule,350% of CMS OPPS Rate,9.48,102,,,Fee Schedule,102% of CMS OPPS Rate,21.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of UHC Fee Schedule,19.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,21.39,230,,,Fee Schedule,230% of CMS OPPS Rate,13.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,25.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,32.92,
TOXOPLASMA (TOXO AB),4087504,CDM,302,RC,86777,HCPCS,Outpatient,,,66.15,39.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,13.81,59.54,
HERPES SIM.VIRUS 1 ABS,4087504,CDM,302,RC,86695,HCPCS,Outpatient,,,45.1,27.06,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
Blood test to monitor for cytomegalovirus,4087504,CDM,302,RC,86644,HCPCS,Outpatient,,,106.15,63.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,95.54,
HERPES SIMPLEX 2 ABS,4087504,CDM,302,RC,86696,HCPCS,Outpatient,,,240.35,144.21,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges,180.26,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,183.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,108.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,115.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,216.32,
Blood test to determine if antibodies exist for rubella,4087504,CDM,302,RC,86762,HCPCS,Outpatient,,,43,25.8,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,50.94,
ANTI HERPES II IGG AB,4087505,CDM,302,RC,86694,HCPCS,Outpatient,,,218.5,131.1,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.95,70,,,percent of total billed charges,70% of total billed charges,163.88,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,174.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,167.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,98.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,152.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,152.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,104.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,196.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,196.65,
"TOXOPLASMA, IGM ABS",4087505,CDM,302,RC,86778,HCPCS,Outpatient,,,66.15,39.69,,51.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges,49.61,75,,,percent of total billed charges,75% of total billed charges,25.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.43,350,,,Fee Schedule,350% of CMS OPPS Rate,14.69,102,,,Fee Schedule,102% of CMS OPPS Rate,50.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,16,100,,,Fee Schedule,100% of UHC Fee Schedule,46.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,33.14,230,,,Fee Schedule,230% of CMS OPPS Rate,31.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,59.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,14.41,59.54,
"ANTI-CMV AB,IGM",4087505,CDM,302,RC,86645,HCPCS,Outpatient,,,106.15,63.69,,59.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,30.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.97,350,,,Fee Schedule,350% of CMS OPPS Rate,17.18,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,18.72,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,38.75,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,100,,,Fee Schedule,100% of CMS OPPS Rate,16.85,95.54,
Blood test to determine if antibodies exist for rubella,4087505,CDM,302,RC,86762,HCPCS,Outpatient,,,43,25.8,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges,32.25,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,32.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,30.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,20.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,38.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,50.94,
MYOGLOBIN ASSAY,4087506,CDM,301,RC,83874,HCPCS,Outpatient,,,262.9,157.74,,45.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.03,70,,,percent of total billed charges,70% of total billed charges,197.18,75,,,percent of total billed charges,75% of total billed charges,23.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.22,350,,,Fee Schedule,350% of CMS OPPS Rate,13.17,102,,,Fee Schedule,102% of CMS OPPS Rate,201.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,118.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14.36,100,,,Fee Schedule,100% of UHC Fee Schedule,184.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,29.71,230,,,Fee Schedule,230% of CMS OPPS Rate,126.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,236.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.92,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,236.61,
Blood test to detect heart enzymes,4087506,CDM,301,RC,82553,HCPCS,Outpatient,,,181.35,108.81,,40.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges,136.01,75,,,percent of total billed charges,75% of total billed charges,20.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.42,350,,,Fee Schedule,350% of CMS OPPS Rate,11.78,102,,,Fee Schedule,102% of CMS OPPS Rate,138.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,12.83,100,,,Fee Schedule,100% of UHC Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,26.56,230,,,Fee Schedule,230% of CMS OPPS Rate,87.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11.55,163.22,
INFECTIOUS AGENT HPV LOW RISK TYPE,4087507,CDM,306,RC,87623,HCPCS,Outpatient,,,316.7,190.02,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221.69,70,,,percent of total billed charges,70% of total billed charges,237.53,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,253.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,242.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,142.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,221.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,152.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,285.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,285.03,
Detection test for human papillomavirus (hpv),4087507,CDM,306,RC,87624,HCPCS,Outpatient,,,238.8,143.28,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges,179.1,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,214.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,214.92,
WEST NILE VIRUS ABS,4087508,CDM,302,RC,86790,HCPCS,Outpatient,,,204.3,122.58,,45.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.01,70,,,percent of total billed charges,70% of total billed charges,153.23,75,,,percent of total billed charges,75% of total billed charges,23.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,163.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.08,350,,,Fee Schedule,350% of CMS OPPS Rate,13.13,102,,,Fee Schedule,102% of CMS OPPS Rate,156.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,91.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,143.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,100,,,Fee Schedule,100% of UHC Fee Schedule,143.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,29.62,230,,,Fee Schedule,230% of CMS OPPS Rate,98.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,100,,,Fee Schedule,100% of CMS OPPS Rate,12.88,183.87,
"PHENOTYPE, DNA HIV W/CLT",4087509,CDM,306,RC,87904,HCPCS,Outpatient,,,66,39.6,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.2,70,,,percent of total billed charges,70% of total billed charges,49.5,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,28.96,100,,,Fee Schedule,100% of UHC Fee Schedule,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,92.28,
"PHENOTYPE, DNA HIV W/CULT",4087509,CDM,306,RC,87903,HCPCS,Outpatient,,,916,549.6,,1729.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,488.66,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,488.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1230.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,641.2,70,,,percent of total billed charges,70% of total billed charges,687,75,,,percent of total billed charges,75% of total billed charges,879.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1710.31,350,,,Fee Schedule,350% of CMS OPPS Rate,498.43,102,,,Fee Schedule,102% of CMS OPPS Rate,700.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,412.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,641.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,549.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,542.95,100,,,Fee Schedule,100% of UHC Fee Schedule,641.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,916,230,,,Fee Schedule,230% of CMS OPPS Rate,439.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,824.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,412.2,1729.85,
BORDETELLA P. ABS,4087510,CDM,302,RC,86615,HCPCS,Outpatient,,,40.7,24.42,,46.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,23.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.16,350,,,Fee Schedule,350% of CMS OPPS Rate,13.45,102,,,Fee Schedule,102% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.65,100,,,Fee Schedule,100% of UHC Fee Schedule,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,30.33,230,,,Fee Schedule,230% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.19,46.69,
RISTOCETIN COFACTOR,4087511,CDM,305,RC,85245,HCPCS,Outpatient,,,91.3,54.78,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges,68.48,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,69.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,63.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,43.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,82.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,82.17,
VON WILLEBRAND FACT AG,4087511,CDM,305,RC,85246,HCPCS,Outpatient,,,193.05,115.83,,81.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges,144.79,75,,,percent of total billed charges,75% of total billed charges,41.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,154.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.29,350,,,Fee Schedule,350% of CMS OPPS Rate,23.39,102,,,Fee Schedule,102% of CMS OPPS Rate,147.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,86.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of UHC Fee Schedule,135.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,52.76,230,,,Fee Schedule,230% of CMS OPPS Rate,92.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,100,,,Fee Schedule,100% of CMS OPPS Rate,22.94,173.75,
Coagulation assessment blood test,4087511,CDM,305,RC,85730,HCPCS,Outpatient,,,152.1,91.26,,21.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges,114.08,75,,,percent of total billed charges,75% of total billed charges,10.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.03,350,,,Fee Schedule,350% of CMS OPPS Rate,6.13,102,,,Fee Schedule,102% of CMS OPPS Rate,116.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,68.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,100,,,Fee Schedule,100% of UHC Fee Schedule,106.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,230,,,Fee Schedule,230% of CMS OPPS Rate,73.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,100,,,Fee Schedule,100% of CMS OPPS Rate,6.01,136.89,
"FACTOR VIII ASSAY, PLASMA",4087511,CDM,305,RC,85240,HCPCS,Outpatient,,,304.2,182.52,,63.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.94,70,,,percent of total billed charges,70% of total billed charges,228.15,75,,,percent of total billed charges,75% of total billed charges,32.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,243.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.64,350,,,Fee Schedule,350% of CMS OPPS Rate,18.25,102,,,Fee Schedule,102% of CMS OPPS Rate,232.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,19.89,100,,,Fee Schedule,100% of UHC Fee Schedule,212.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,41.17,230,,,Fee Schedule,230% of CMS OPPS Rate,146.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,273.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,100,,,Fee Schedule,100% of CMS OPPS Rate,17.89,273.78,
EXTRACTABLE N AG IGG ABS,4087512,CDM,302,RC,86235,HCPCS,Outpatient,,,54,32.4,,63.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,32.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.75,350,,,Fee Schedule,350% of CMS OPPS Rate,18.28,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.93,100,,,Fee Schedule,100% of UHC Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.23,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.15,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.15,63.47,
Chemical test of the blood to measure presence or concentration of a substance in the blood,4087513,CDM,301,RC,83516,HCPCS,Outpatient,,,116.6,69.96,,40.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,81.62,70,,,percent of total billed charges,70% of total billed charges,87.45,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,93.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.35,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,89.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,52.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,12.82,100,,,Fee Schedule,100% of UHC Fee Schedule,81.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.51,230,,,Fee Schedule,230% of CMS OPPS Rate,55.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,104.94,
NEPHELOMETRY EA,4087514,CDM,300,RC,83883,HCPCS,Outpatient,,,41,24.6,,48.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,24.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.6,350,,,Fee Schedule,350% of CMS OPPS Rate,13.87,102,,,Fee Schedule,102% of CMS OPPS Rate,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of UHC Fee Schedule,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,31.28,230,,,Fee Schedule,230% of CMS OPPS Rate,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13.6,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,48.14,
ASPERGILLUS ABS,4087515,CDM,302,RC,86606,HCPCS,Outpatient,,,50.6,30.36,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
HEPATITIS B AMPL PROBE,4087516,CDM,300,RC,87516,HCPCS,Outpatient,,,265.65,159.39,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,185.96,70,,,percent of total billed charges,70% of total billed charges,199.24,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,212.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,203.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,119.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,185.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,185.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,127.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,239.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,239.09,
"HEP. B,VIRUS QUANT",4087517,CDM,306,RC,87517,HCPCS,Outpatient,,,275,165,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,247.5,
ASPERGILLUS ABS,4087518,CDM,302,RC,86606,HCPCS,Outpatient,,,50.6,30.36,,53.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges,37.95,75,,,percent of total billed charges,75% of total billed charges,27.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.67,350,,,Fee Schedule,350% of CMS OPPS Rate,15.35,102,,,Fee Schedule,102% of CMS OPPS Rate,38.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.73,100,,,Fee Schedule,100% of UHC Fee Schedule,35.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,34.61,230,,,Fee Schedule,230% of CMS OPPS Rate,24.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15.05,53.27,
BARTONELLA ABS,4087520,CDM,302,RC,86611,HCPCS,Outpatient,,,96.3,57.78,,36.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,67.41,70,,,percent of total billed charges,70% of total billed charges,72.23,75,,,percent of total billed charges,75% of total billed charges,18.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.63,350,,,Fee Schedule,350% of CMS OPPS Rate,10.38,102,,,Fee Schedule,102% of CMS OPPS Rate,73.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.3,100,,,Fee Schedule,100% of UHC Fee Schedule,67.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,23.41,230,,,Fee Schedule,230% of CMS OPPS Rate,46.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,86.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10.18,86.67,
HEPATITIS C RNA PROBE,4087521,CDM,300,RC,87521,HCPCS,Outpatient,,,143.55,86.13,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges,107.66,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,129.2,
HEPATITIS C QUANTIFICATION,4087522,CDM,300,RC,87522,HCPCS,Outpatient,,,268.95,161.37,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,188.27,70,,,percent of total billed charges,70% of total billed charges,201.71,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,215.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,205.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,121.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,188.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,129.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,242.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,242.06,
SPECIMEN COLLECTION FEE,4087523,CDM,300,RC,C9803,HCPCS,Outpatient,,,70,42,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,80.32,
SAR COVID-19,4087524,CDM,300,RC,U0002,HCPCS,Outpatient,,,714,428.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges,535.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,571.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,546.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,100,,,Fee Schedule,100% of UHC Fee Schedule,499.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,342.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,642.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,642.6,
SPECIMEN COLLECTION FEE,4087524,CDM,300,RC,C9803,HCPCS,Outpatient,,,70,42,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,80.32,
HERPES SIMPLEX DNA PROBE,4087529,CDM,300,RC,87529,HCPCS,Outpatient,,,242.55,145.53,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,169.79,70,,,percent of total billed charges,70% of total billed charges,181.91,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,194.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,185.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,169.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,145.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,169.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,116.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,218.3,
HERPES S.VIRUS QUANT,4087530,CDM,300,RC,87530,HCPCS,Outpatient,,,129,77.4,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.3,70,,,percent of total billed charges,70% of total billed charges,96.75,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,98.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,58.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,61.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,116.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,151.65,
INFECTIOUS AGENT BY DNA HPV6,4087532,CDM,300,RC,87532,HCPCS,Outpatient,,,238.8,143.28,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges,179.1,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,214.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,214.92,
HPV 6 DNA QUANTITATIVE,4087533,CDM,300,RC,87533,HCPCS,Outpatient,,,698,418.8,,147.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,488.6,70,,,percent of total billed charges,70% of total billed charges,523.5,75,,,percent of total billed charges,75% of total billed charges,75.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,558.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.16,350,,,Fee Schedule,350% of CMS OPPS Rate,42.59,102,,,Fee Schedule,102% of CMS OPPS Rate,533.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,314.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,488.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.4,100,,,Fee Schedule,100% of UHC Fee Schedule,488.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,96.04,230,,,Fee Schedule,230% of CMS OPPS Rate,335.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,628.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,24.93,628.2,
HIV 2 AMPLIF NA PROBE,4087538,CDM,301,RC,87538,HCPCS,Outpatient,,,328,196.8,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,229.6,70,,,percent of total billed charges,70% of total billed charges,246,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,250.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,147.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,229.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,229.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,157.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,295.2,
INFECTIOUS AGENT BY DNA PNEUMOPHILA,4087541,CDM,306,RC,87541,HCPCS,Outpatient,,,230.72,138.43,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,161.5,70,,,percent of total billed charges,70% of total billed charges,173.04,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,184.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,176.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,103.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,161.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,110.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,207.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,207.65,
MYCOBACTERIA DNA RNA PROBE,4087551,CDM,300,RC,87551,HCPCS,Outpatient,,,700,420,,170.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,48.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges,525,75,,,percent of total billed charges,75% of total billed charges,86.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.84,350,,,Fee Schedule,350% of CMS OPPS Rate,49.2,102,,,Fee Schedule,102% of CMS OPPS Rate,535.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,315,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,420,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,43.42,100,,,Fee Schedule,100% of UHC Fee Schedule,490,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,110.95,230,,,Fee Schedule,230% of CMS OPPS Rate,336,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,630,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,43.42,630,
MYCOBACTERIA AVIUM BY AMP PROBE,4087561,CDM,306,RC,87561,HCPCS,Outpatient,,,270,162,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,189,70,,,percent of total billed charges,70% of total billed charges,202.5,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,216,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,206.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,121.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,189,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,129.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,243,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,243,
MYCOPLASMA PNEUM PROB,4087581,CDM,300,RC,87501,HCPCS,Outpatient,,,154,92.4,,181.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,129.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,107.8,70,,,percent of total billed charges,70% of total billed charges,115.5,75,,,percent of total billed charges,75% of total billed charges,92.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,123.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.58,350,,,Fee Schedule,350% of CMS OPPS Rate,52.33,102,,,Fee Schedule,102% of CMS OPPS Rate,117.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,69.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,92.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,57.02,100,,,Fee Schedule,100% of UHC Fee Schedule,107.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,230,,,Fee Schedule,230% of CMS OPPS Rate,73.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of CMS OPPS Rate,51.31,181.63,
Blood test for an STD,4087591,CDM,306,RC,87591,HCPCS,Outpatient,,,185.4,111.24,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges,139.05,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,141.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,129.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,88.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,166.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,166.86,
INFECTIOUS AGENT HPV LOW RISK TYPE,4087621,CDM,306,RC,87623,HCPCS,Outpatient,,,316.7,190.02,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221.69,70,,,percent of total billed charges,70% of total billed charges,237.53,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,253.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,242.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,142.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,221.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,152.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,285.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,285.03,
Detection test for human papillomavirus (hpv),4087624,CDM,306,RC,87624,HCPCS,Outpatient,,,238.8,143.28,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges,179.1,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,214.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,214.92,
"INFECTIOUS AGENT DNA HPV TYPE 16, 18",4087625,CDM,300,RC,87625,HCPCS,Outpatient,,,239,143.4,,143.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,72.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.92,350,,,Fee Schedule,350% of CMS OPPS Rate,41.36,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,93.26,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,39,215.1,
INFECTIOUS AGENT BY DNA RESP VIRUS,4087633,CDM,300,RC,87633,HCPCS,Outpatient,,,1250,750,,1475.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,416.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1049.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,875,70,,,percent of total billed charges,70% of total billed charges,937.5,75,,,percent of total billed charges,75% of total billed charges,750.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1458.73,350,,,Fee Schedule,350% of CMS OPPS Rate,425.11,102,,,Fee Schedule,102% of CMS OPPS Rate,956.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,215.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,562.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,875,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,958.59,230,,,Fee Schedule,230% of CMS OPPS Rate,600,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1125,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,416.78,100,,,Fee Schedule,100% of CMS OPPS Rate,195.88,1475.4,
Blood test for strep infection,4087653,CDM,306,RC,87653,HCPCS,Outpatient,,,239,143.4,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges,179.25,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,191.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,182.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,107.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,167.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,114.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,215.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,215.1,
TRICHOMONUS VAGINALIS DIR PROB,4087660,CDM,306,RC,87660,HCPCS,Outpatient,,,136.6,81.96,,70.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.48,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,95.62,70,,,percent of total billed charges,70% of total billed charges,102.45,75,,,percent of total billed charges,75% of total billed charges,36.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.17,350,,,Fee Schedule,350% of CMS OPPS Rate,20.45,102,,,Fee Schedule,102% of CMS OPPS Rate,104.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,61.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of UHC Fee Schedule,95.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.11,230,,,Fee Schedule,230% of CMS OPPS Rate,65.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,122.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,122.94,
Blood test for an STD,4087661,CDM,306,RC,87661,HCPCS,Outpatient,,,280,168,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,252,
BACTERIAL DETECTION PROBE,4087798,CDM,300,RC,87798,HCPCS,Outpatient,,,105,63,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,124.21,
"INFECTIOUS A. DNA, QUANT",4087799,CDM,300,RC,87799,HCPCS,Outpatient,,,245.85,147.51,,151.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,172.1,70,,,percent of total billed charges,70% of total billed charges,184.39,75,,,percent of total billed charges,75% of total billed charges,77.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,196.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.94,350,,,Fee Schedule,350% of CMS OPPS Rate,43.69,102,,,Fee Schedule,102% of CMS OPPS Rate,188.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,110.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of UHC Fee Schedule,172.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.53,230,,,Fee Schedule,230% of CMS OPPS Rate,118.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,221.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.84,100,,,Fee Schedule,100% of CMS OPPS Rate,16.7,221.27,
Blood test to determine genetic material of certain infectious agents,4087801,CDM,300,RC,87801,HCPCS,Outpatient,,,478.8,287.28,,248.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,53.11,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,70.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,335.16,70,,,percent of total billed charges,70% of total billed charges,359.1,75,,,percent of total billed charges,75% of total billed charges,126.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,383.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,245.7,350,,,Fee Schedule,350% of CMS OPPS Rate,71.6,102,,,Fee Schedule,102% of CMS OPPS Rate,366.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,215.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,77.99,100,,,Fee Schedule,100% of UHC Fee Schedule,335.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,161.46,230,,,Fee Schedule,230% of CMS OPPS Rate,229.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,430.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.11,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,100,,,Fee Schedule,100% of CMS OPPS Rate,53.11,430.92,
Test for strep A,4087880,CDM,306,RC,87880,HCPCS,Outpatient,,,108.24,64.94,,58.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges,81.18,75,,,percent of total billed charges,75% of total billed charges,29.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.85,350,,,Fee Schedule,350% of CMS OPPS Rate,16.86,102,,,Fee Schedule,102% of CMS OPPS Rate,82.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,48.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,100,,,Fee Schedule,100% of UHC Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,38.01,230,,,Fee Schedule,230% of CMS OPPS Rate,51.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,97.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,14.88,97.42,
INFECTIOUS AGENT AG OTHER,4087899,CDM,306,RC,87899,HCPCS,Outpatient,,,108.24,64.94,,56.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges,81.18,75,,,percent of total billed charges,75% of total billed charges,28.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,86.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.24,350,,,Fee Schedule,350% of CMS OPPS Rate,16.39,102,,,Fee Schedule,102% of CMS OPPS Rate,82.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,48.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,100,,,Fee Schedule,100% of UHC Fee Schedule,75.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,36.96,230,,,Fee Schedule,230% of CMS OPPS Rate,51.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,16.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.46,97.42,
INFECTIOUS AGENT SUSC. PHENOTYPE,4087900,CDM,306,RC,87900,HCPCS,Outpatient,,,1176.14,705.68,,461.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,130.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,328.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,823.3,70,,,percent of total billed charges,70% of total billed charges,882.11,75,,,percent of total billed charges,75% of total billed charges,234.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,940.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,456.22,350,,,Fee Schedule,350% of CMS OPPS Rate,132.95,102,,,Fee Schedule,102% of CMS OPPS Rate,899.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,529.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,823.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,144.83,100,,,Fee Schedule,100% of UHC Fee Schedule,823.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,299.8,230,,,Fee Schedule,230% of CMS OPPS Rate,564.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,100,,,Fee Schedule,100% of CMS OPPS Rate,130.35,1058.53,
INFECTIOUS AGENT GENOTYPE,4087901,CDM,309,RC,87901,HCPCS,Outpatient,,,772,463.2,,911.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,257.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,648.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,540.4,70,,,percent of total billed charges,70% of total billed charges,579,75,,,percent of total billed charges,75% of total billed charges,463.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.07,350,,,Fee Schedule,350% of CMS OPPS Rate,262.59,102,,,Fee Schedule,102% of CMS OPPS Rate,590.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,347.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,540.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,463.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,286.06,100,,,Fee Schedule,100% of UHC Fee Schedule,540.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,592.13,230,,,Fee Schedule,230% of CMS OPPS Rate,370.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,694.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,911.37,
"HEPATITIS C, GENOTYPE",4087902,CDM,306,RC,87902,HCPCS,Outpatient,,,772,463.2,,911.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,257.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,648.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,540.4,70,,,percent of total billed charges,70% of total billed charges,579,75,,,percent of total billed charges,75% of total billed charges,463.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,617.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.07,350,,,Fee Schedule,350% of CMS OPPS Rate,262.59,102,,,Fee Schedule,102% of CMS OPPS Rate,590.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,347.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,540.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,463.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,286.06,100,,,Fee Schedule,100% of UHC Fee Schedule,540.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,592.13,230,,,Fee Schedule,230% of CMS OPPS Rate,370.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,694.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,911.37,
"PHENOTYPE, DNA HIV W/CULT",4087903,CDM,306,RC,87903,HCPCS,Outpatient,,,916,549.6,,1729.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,488.66,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,488.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1230.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,641.2,70,,,percent of total billed charges,70% of total billed charges,687,75,,,percent of total billed charges,75% of total billed charges,879.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1710.31,350,,,Fee Schedule,350% of CMS OPPS Rate,498.43,102,,,Fee Schedule,102% of CMS OPPS Rate,700.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,412.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,641.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,549.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,542.95,100,,,Fee Schedule,100% of UHC Fee Schedule,641.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,916,230,,,Fee Schedule,230% of CMS OPPS Rate,439.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,824.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,488.66,100,,,Fee Schedule,100% of CMS OPPS Rate,412.2,1729.85,
"PHENOTYPE, DNA HIV W/CLT",4087904,CDM,306,RC,87904,HCPCS,Outpatient,,,66,39.6,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.2,70,,,percent of total billed charges,70% of total billed charges,49.5,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,52.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,50.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,28.96,100,,,Fee Schedule,100% of UHC Fee Schedule,46.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,31.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,92.28,
GENOTYPE ANALYSIS BY DNA HIV1,4087906,CDM,306,RC,87906,HCPCS,Outpatient,,,878,526.8,,455.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,128.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,128.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,324.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,614.6,70,,,percent of total billed charges,70% of total billed charges,658.5,75,,,percent of total billed charges,75% of total billed charges,231.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,702.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,450.55,350,,,Fee Schedule,350% of CMS OPPS Rate,131.3,102,,,Fee Schedule,102% of CMS OPPS Rate,671.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,395.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,614.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,526.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,143.03,100,,,Fee Schedule,100% of UHC Fee Schedule,614.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,296.07,230,,,Fee Schedule,230% of CMS OPPS Rate,421.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,790.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,100,,,Fee Schedule,100% of CMS OPPS Rate,128.72,790.2,
INFECTIOUS AGENT GENOTYPE CMV,4087910,CDM,306,RC,87910,HCPCS,Outpatient,,,1765.75,1059.45,,911.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,257.45,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,257.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,648.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1236.03,70,,,percent of total billed charges,70% of total billed charges,1324.31,75,,,percent of total billed charges,75% of total billed charges,463.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1412.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,901.07,350,,,Fee Schedule,350% of CMS OPPS Rate,262.59,102,,,Fee Schedule,102% of CMS OPPS Rate,1350.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,794.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1236.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1059.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,286.06,100,,,Fee Schedule,100% of UHC Fee Schedule,1236.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,592.13,230,,,Fee Schedule,230% of CMS OPPS Rate,847.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1589.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,100,,,Fee Schedule,100% of CMS OPPS Rate,257.45,1589.18,
HIV TROPISM ASSAY,4087999,CDM,300,RC,87999,HCPCS,Outpatient,,,1662.15,997.29,,,,,,Other,Not Separately reimbursable,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.51,70,,,percent of total billed charges,70% of total billed charges,1246.61,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1329.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,286.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1163.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,997.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1163.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1495.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.46,1495.94,
"TESTOSTERONE, FREE",4088065,CDM,300,RC,84402,HCPCS,Outpatient,,,184.8,110.88,,90.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.36,70,,,percent of total billed charges,70% of total billed charges,138.6,75,,,percent of total billed charges,75% of total billed charges,45.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.14,350,,,Fee Schedule,350% of CMS OPPS Rate,25.97,102,,,Fee Schedule,102% of CMS OPPS Rate,141.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,83.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,28.31,100,,,Fee Schedule,100% of UHC Fee Schedule,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,58.58,230,,,Fee Schedule,230% of CMS OPPS Rate,88.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,166.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,166.32,
"CORTISOL (CORTISOL, FREE)",4088075,CDM,301,RC,82530,HCPCS,Outpatient,,,139.7,83.82,,59.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.71,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges,104.78,75,,,percent of total billed charges,75% of total billed charges,30.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.48,350,,,Fee Schedule,350% of CMS OPPS Rate,17.04,102,,,Fee Schedule,102% of CMS OPPS Rate,106.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,62.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of UHC Fee Schedule,97.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,38.43,230,,,Fee Schedule,230% of CMS OPPS Rate,67.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,125.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16.71,125.73,
CYTOPATHOLOGY FISH 3-5 SPECIMENS,4088120,CDM,300,RC,88120,HCPCS,Outpatient,,,1287.43,772.46,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,297.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,901.2,70,,,percent of total billed charges,70% of total billed charges,965.57,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1029.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,984.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,579.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,901.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,772.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,901.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,617.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1158.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,1158.69,
Cervical cancer screening test with interpretation,4088141,CDM,311,RC,88141,HCPCS,Outpatient,,,152.56,91.54,,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.79,70,,,percent of total billed charges,70% of total billed charges,114.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,122.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.81,100,,,Fee Schedule,100% of UHC Fee Schedule,106.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.99,137.3,
"CYTOPATH, EVAL FNA IMMEDIATE",4088177,CDM,311,RC,88177,HCPCS,Outpatient,,,44.56,26.74,,,,,,Other,Not Separately reimbursable,18.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,70,,,percent of total billed charges,70% of total billed charges,33.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,35.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.13,100,,,Fee Schedule,100% of UHC Fee Schedule,31.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.13,40.1,
FLOW CYTOMETRY 1ST MARKER,4088184,CDM,311,RC,88184,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,38.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,38.33,1043.05,
FLOW CYTOMETRY ADD MARKER,4088185,CDM,311,RC,88185,HCPCS,Outpatient,,,96,57.6,,,,,,Other,Not Separately reimbursable,18.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.2,70,,,percent of total billed charges,70% of total billed charges,72,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.54,100,,,Fee Schedule,100% of UHC Fee Schedule,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,86.4,
"FLOW CYTOMETRY INTERP,2-8",4088187,CDM,311,RC,88187,HCPCS,Outpatient,,,162,97.2,,,,,,Other,Not Separately reimbursable,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.42,100,,,Fee Schedule,100% of UHC Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,145.8,
FLOW CYTOMETRY INTERP 9 TO 15 CELLS,4088188,CDM,311,RC,88188,HCPCS,Outpatient,,,435.5,261.3,,,,,,Other,Not Separately reimbursable,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.12,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,304.85,70,,,percent of total billed charges,70% of total billed charges,326.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,348.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.94,100,,,Fee Schedule,100% of UHC Fee Schedule,304.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,391.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.94,391.95,
FLOW CYTOMETRY INTERP 16 OR MORE,4088189,CDM,311,RC,88189,HCPCS,Outpatient,,,162,97.2,,,,,,Other,Not Separately reimbursable,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.04,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.03,100,,,Fee Schedule,100% of UHC Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,220.04,
TISSUE CULT NEOPLASTIC TUMOR,4088239,CDM,311,RC,88239,HCPCS,Outpatient,,,336,201.6,,522.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,147.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,147.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,371.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,235.2,70,,,percent of total billed charges,70% of total billed charges,252,75,,,percent of total billed charges,75% of total billed charges,265.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,516.32,350,,,Fee Schedule,350% of CMS OPPS Rate,150.47,102,,,Fee Schedule,102% of CMS OPPS Rate,257.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,151.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,100,,,Fee Schedule,100% of UHC Fee Schedule,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,336,230,,,Fee Schedule,230% of CMS OPPS Rate,161.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,77.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of CMS OPPS Rate,77.9,522.22,
CHROM ALALYSIS CNT 5 CELLS,4088261,CDM,311,RC,88261,HCPCS,Outpatient,,,1252,751.2,,935.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,176.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,264.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,264.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,538.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,876.4,70,,,percent of total billed charges,70% of total billed charges,939,75,,,percent of total billed charges,75% of total billed charges,475.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1001.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,925.18,350,,,Fee Schedule,350% of CMS OPPS Rate,269.62,102,,,Fee Schedule,102% of CMS OPPS Rate,957.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,876.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,751.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,237.91,100,,,Fee Schedule,100% of UHC Fee Schedule,876.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,607.98,230,,,Fee Schedule,230% of CMS OPPS Rate,600.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,176.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,264.33,100,,,Fee Schedule,100% of CMS OPPS Rate,176.64,1126.8,
CHROM. ANALYSIS 20-50CELL,4088264,CDM,311,RC,88264,HCPCS,Outpatient,,,434,260.4,,511.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,144.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,144.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,313.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,303.8,70,,,percent of total billed charges,70% of total billed charges,325.5,75,,,percent of total billed charges,75% of total billed charges,260.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.13,350,,,Fee Schedule,350% of CMS OPPS Rate,147.5,102,,,Fee Schedule,102% of CMS OPPS Rate,332.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,195.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,303.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,260.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of UHC Fee Schedule,303.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,332.6,230,,,Fee Schedule,230% of CMS OPPS Rate,208.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,390.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,144.61,100,,,Fee Schedule,100% of CMS OPPS Rate,138.49,511.91,
CHROM. HYBRIDIZATION,4088273,CDM,311,RC,88273,HCPCS,Outpatient,,,83,49.8,,123.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,80.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,62.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,121.83,350,,,Fee Schedule,350% of CMS OPPS Rate,35.5,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,35.69,100,,,Fee Schedule,100% of UHC Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,80.06,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,123.22,
MOLECULAR CYTOGENETICS INTERF,4088274,CDM,311,RC,88274,HCPCS,Outpatient,,,302.4,181.44,,150.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,87.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,211.68,70,,,percent of total billed charges,70% of total billed charges,226.8,75,,,percent of total billed charges,75% of total billed charges,76.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.33,350,,,Fee Schedule,350% of CMS OPPS Rate,43.22,102,,,Fee Schedule,102% of CMS OPPS Rate,231.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,136.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,100,,,Fee Schedule,100% of UHC Fee Schedule,211.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,97.47,230,,,Fee Schedule,230% of CMS OPPS Rate,145.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,272.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,42.38,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,272.16,
MOLECULAR CYTOGEN 100 300 CELLS,4088275,CDM,311,RC,88275,HCPCS,Outpatient,,,326.14,195.68,,181.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.19,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,228.3,70,,,percent of total billed charges,70% of total billed charges,244.61,75,,,percent of total billed charges,75% of total billed charges,92.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,260.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.16,350,,,Fee Schedule,350% of CMS OPPS Rate,52.21,102,,,Fee Schedule,102% of CMS OPPS Rate,249.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,146.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,228.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,46.07,100,,,Fee Schedule,100% of UHC Fee Schedule,228.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,117.73,230,,,Fee Schedule,230% of CMS OPPS Rate,156.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,293.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,51.19,100,,,Fee Schedule,100% of CMS OPPS Rate,46.07,293.53,
CHROM. ANALY ADD KARYOTES,4088280,CDM,311,RC,88280,HCPCS,Outpatient,,,121.5,72.9,,118.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,32.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges,91.13,75,,,percent of total billed charges,75% of total billed charges,60.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.14,350,,,Fee Schedule,350% of CMS OPPS Rate,34.13,102,,,Fee Schedule,102% of CMS OPPS Rate,92.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,54.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,30.12,100,,,Fee Schedule,100% of UHC Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,76.98,230,,,Fee Schedule,230% of CMS OPPS Rate,58.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,109.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,30.12,118.48,
CHROM ANALYSIS ADD CELLS,4088285,CDM,311,RC,88285,HCPCS,Outpatient,,,135,81,,95.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,54.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,94.5,70,,,percent of total billed charges,70% of total billed charges,101.25,75,,,percent of total billed charges,75% of total billed charges,48.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,108,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.18,350,,,Fee Schedule,350% of CMS OPPS Rate,27.44,102,,,Fee Schedule,102% of CMS OPPS Rate,103.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,60.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of UHC Fee Schedule,94.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,61.89,230,,,Fee Schedule,230% of CMS OPPS Rate,64.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,121.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,26.91,100,,,Fee Schedule,100% of CMS OPPS Rate,6.68,121.5,
CYTOGENETICS INTERP.,4088291,CDM,311,RC,88291,HCPCS,Outpatient,,,95.4,57.24,,,,,,Other,Not Separately reimbursable,6.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.78,70,,,percent of total billed charges,70% of total billed charges,71.55,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,76.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,66.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.07,85.86,
"CONSULT & REPORT, REFERED",4088323,CDM,312,RC,88323,HCPCS,Outpatient,,,134,80.4,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges,100.5,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,102.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,64.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,120.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,70.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,161.36,
CONSULT WITH COMPREHENSIVE REVIEW,4088325,CDM,312,RC,88325,HCPCS,Outpatient,,,884.25,530.55,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,56.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,618.98,70,,,percent of total billed charges,70% of total billed charges,663.19,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,707.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,676.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,397.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,618.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,530.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,100,,,Fee Schedule,100% of UHC Fee Schedule,618.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,424.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,795.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.23,795.83,
IMMUNOFLUORESCENT  EA ADDL  SNGL AB,4088350,CDM,310,RC,88350,HCPCS,Outpatient,,,193.76,116.26,,,,,,Other,Not Separately reimbursable,74.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.63,70,,,percent of total billed charges,70% of total billed charges,145.32,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,155.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.2,100,,,Fee Schedule,100% of UHC Fee Schedule,135.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.2,174.38,
MORPHOMETRIC ANAL HER 2 NEU,4088360,CDM,312,RC,88360,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,60.8,506.06,
MORPHOMETRIC ANALYSIS TUMOR,4088361,CDM,312,RC,88361,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,105.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,105.39,1043.05,
NERVE TEASING PREPARATION,4088362,CDM,312,RC,88362,HCPCS,Outpatient,,,950,570,,2498.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,705.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1102.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,665,70,,,percent of total billed charges,70% of total billed charges,712.5,75,,,percent of total billed charges,75% of total billed charges,1270.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2470.73,350,,,Fee Schedule,350% of CMS OPPS Rate,720.04,103,,,Fee Schedule,103% of CMS OPPS Rate,726.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,163.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,427.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,665,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,570,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,486.86,100,,,Fee Schedule,100% of UHC Fee Schedule,665,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.62,100,,,Fee Schedule,100% of CMS OPPS Rate,456,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,855,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,705.92,100,,,Fee Schedule,100% of CMS OPPS Rate,148.87,2498.97,
IN SITU HYBRIDIZATION PER SPEC (EG FISH),4088364,CDM,312,RC,88364,HCPCS,Outpatient,,,445.2,267.12,,,,,,Other,Not Separately reimbursable,85.85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.64,70,,,percent of total billed charges,70% of total billed charges,333.9,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,356.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,311.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,267.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.45,100,,,Fee Schedule,100% of UHC Fee Schedule,311.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.85,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.85,400.68,
IN SITU HYBRIDIZATION PROBE,4088365,CDM,312,RC,88365,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,61.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,61.04,506.06,
MORPHOMETRIC ANALYSIS IN SITU,4088367,CDM,312,RC,88367,HCPCS,Outpatient,,,804.6,482.76,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,563.22,70,,,percent of total billed charges,70% of total billed charges,603.45,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,643.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,615.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,362.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,563.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,482.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,563.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,386.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,724.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,98.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,98.24,1043.05,
MORPHOMETRIC ANALYSIS EA,4088368,CDM,312,RC,88368,HCPCS,Outpatient,,,630,378,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,116.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,116.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,116.06,1043.05,
PROTEIN ANALYSIS TISSUE W BLOT,4088372,CDM,312,RC,88372,HCPCS,Outpatient,,,157,94.2,,,,,,Other,Not Separately reimbursable,20.47,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.9,70,,,percent of total billed charges,70% of total billed charges,117.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,125.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.27,100,,,Fee Schedule,100% of UHC Fee Schedule,109.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.47,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.47,141.3,
MORPHOMETRIC ANALYSIS AUTOMATED,4088373,CDM,312,RC,88373,HCPCS,Outpatient,,,330,198,,,,,,Other,Not Separately reimbursable,53.82,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231,70,,,percent of total billed charges,70% of total billed charges,247.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,264,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.33,100,,,Fee Schedule,100% of UHC Fee Schedule,231,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,53.82,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.33,297,
MORPHOMETRIC ANALYSIS IN SITU QUANT EA,4088374,CDM,312,RC,88374,HCPCS,Outpatient,,,664.82,398.89,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,179.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,465.37,70,,,percent of total billed charges,70% of total billed charges,498.62,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,531.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,508.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,299.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,465.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,465.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,319.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,598.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,179.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,598.34,
MORPHOMETRIC ANALYSIS EA MULTIPLX PROBE,4088377,CDM,312,RC,88377,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,189.43,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.43,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,506.06,
MICRODISSECTION MANUAL,4088381,CDM,312,RC,88381,HCPCS,Outpatient,,,466.2,279.72,,,,,,Other,Not Separately reimbursable,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.34,70,,,percent of total billed charges,70% of total billed charges,349.65,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,372.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,326.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.78,100,,,Fee Schedule,100% of UHC Fee Schedule,326.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,419.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.05,419.58,
"HIV-1, DNA DETECTOR,BLD",4088925,CDM,300,RC,87535,HCPCS,Outpatient,,,243.9,146.34,,124.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.09,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,170.73,70,,,percent of total billed charges,70% of total billed charges,182.93,75,,,percent of total billed charges,75% of total billed charges,63.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,195.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.81,350,,,Fee Schedule,350% of CMS OPPS Rate,35.79,102,,,Fee Schedule,102% of CMS OPPS Rate,186.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,109.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,170.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39,100,,,Fee Schedule,100% of UHC Fee Schedule,170.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,80.7,230,,,Fee Schedule,230% of CMS OPPS Rate,117.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,219.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,219.51,
CULTURE-CHLAMYDIA-MISC SP,4089001,CDM,306,RC,87110,HCPCS,Outpatient,,,50,30,,69.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,35.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.6,350,,,Fee Schedule,350% of CMS OPPS Rate,19.99,102,,,Fee Schedule,102% of CMS OPPS Rate,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,21.77,100,,,Fee Schedule,100% of UHC Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,45.08,230,,,Fee Schedule,230% of CMS OPPS Rate,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,69.38,
ANTI-INTRINSIC FACT ANTIB,4089006,CDM,302,RC,86340,HCPCS,Outpatient,,,158.85,95.31,,53.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,111.2,70,,,percent of total billed charges,70% of total billed charges,119.14,75,,,percent of total billed charges,75% of total billed charges,27.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,127.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.78,350,,,Fee Schedule,350% of CMS OPPS Rate,15.38,102,,,Fee Schedule,102% of CMS OPPS Rate,121.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,71.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16.75,100,,,Fee Schedule,100% of UHC Fee Schedule,111.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,34.68,230,,,Fee Schedule,230% of CMS OPPS Rate,76.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,142.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7.83,142.97,
VIP-VASOACT POLYPEPTIDE,4089012,CDM,301,RC,84586,HCPCS,Outpatient,,,365.85,219.51,,125.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,35.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.1,70,,,percent of total billed charges,70% of total billed charges,274.39,75,,,percent of total billed charges,75% of total billed charges,63.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.65,350,,,Fee Schedule,350% of CMS OPPS Rate,36.03,102,,,Fee Schedule,102% of CMS OPPS Rate,279.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,164.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,39.26,100,,,Fee Schedule,100% of UHC Fee Schedule,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,81.25,230,,,Fee Schedule,230% of CMS OPPS Rate,175.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,329.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35.33,329.27,
ANTI-HISTOPLASMA ANTIBODY,4089014,CDM,302,RC,86698,HCPCS,Outpatient,,,97.2,58.32,,48.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.79,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.04,70,,,percent of total billed charges,70% of total billed charges,72.9,75,,,percent of total billed charges,75% of total billed charges,24.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,77.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.26,350,,,Fee Schedule,350% of CMS OPPS Rate,14.06,102,,,Fee Schedule,102% of CMS OPPS Rate,74.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,43.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.89,100,,,Fee Schedule,100% of UHC Fee Schedule,68.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,31.71,230,,,Fee Schedule,230% of CMS OPPS Rate,46.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,87.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,87.48,
Blood test to monitor for cytomegalovirus,4089015,CDM,302,RC,86644,HCPCS,Outpatient,,,106.15,63.69,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges,79.61,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,81.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,47.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,74.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,50.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,95.54,
DHEA,4089018,CDM,301,RC,82626,HCPCS,Outpatient,,,276.1,165.66,,89.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.27,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.27,70,,,percent of total billed charges,70% of total billed charges,207.08,75,,,percent of total billed charges,75% of total billed charges,45.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.44,350,,,Fee Schedule,350% of CMS OPPS Rate,25.77,102,,,Fee Schedule,102% of CMS OPPS Rate,211.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,124.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,193.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.08,100,,,Fee Schedule,100% of UHC Fee Schedule,193.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,58.12,230,,,Fee Schedule,230% of CMS OPPS Rate,132.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,248.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,100,,,Fee Schedule,100% of CMS OPPS Rate,25.27,248.49,
ALPHA-1 ANTITRYPSIN,4089021,CDM,301,RC,82103,HCPCS,Outpatient,,,206.8,124.08,,47.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.76,70,,,percent of total billed charges,70% of total billed charges,155.1,75,,,percent of total billed charges,75% of total billed charges,24.19,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.04,350,,,Fee Schedule,350% of CMS OPPS Rate,13.7,102,,,Fee Schedule,102% of CMS OPPS Rate,158.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,93.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,14.93,100,,,Fee Schedule,100% of UHC Fee Schedule,144.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,30.91,230,,,Fee Schedule,230% of CMS OPPS Rate,99.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,186.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,100,,,Fee Schedule,100% of CMS OPPS Rate,13.44,186.12,
GASTRIN,4089023,CDM,301,RC,82941,HCPCS,Outpatient,,,138,82.8,,62.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.63,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,44.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.6,70,,,percent of total billed charges,70% of total billed charges,103.5,75,,,percent of total billed charges,75% of total billed charges,31.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,110.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.7,350,,,Fee Schedule,350% of CMS OPPS Rate,17.98,102,,,Fee Schedule,102% of CMS OPPS Rate,105.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,62.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,96.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,100,,,Fee Schedule,100% of UHC Fee Schedule,96.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,230,,,Fee Schedule,230% of CMS OPPS Rate,66.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,124.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,100,,,Fee Schedule,100% of CMS OPPS Rate,17.63,124.2,
Acute hepatitis panel,4089040,CDM,301,RC,80074,HCPCS,Outpatient,,,143,85.8,,168.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.63,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,119.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.1,70,,,percent of total billed charges,70% of total billed charges,107.25,75,,,percent of total billed charges,75% of total billed charges,85.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.7,350,,,Fee Schedule,350% of CMS OPPS Rate,48.58,102,,,Fee Schedule,102% of CMS OPPS Rate,109.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,64.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,52.93,100,,,Fee Schedule,100% of UHC Fee Schedule,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,109.54,230,,,Fee Schedule,230% of CMS OPPS Rate,68.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,128.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,100,,,Fee Schedule,100% of CMS OPPS Rate,47.63,168.61,
FLUORESCEN AGENT AB TITER,4089050,CDM,302,RC,86256,HCPCS,Outpatient,,,39.05,23.43,,42.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,27.34,70,,,percent of total billed charges,70% of total billed charges,29.29,75,,,percent of total billed charges,75% of total billed charges,21.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,31.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.17,350,,,Fee Schedule,350% of CMS OPPS Rate,12.29,102,,,Fee Schedule,102% of CMS OPPS Rate,29.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13.39,100,,,Fee Schedule,100% of UHC Fee Schedule,27.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.71,230,,,Fee Schedule,230% of CMS OPPS Rate,18.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12.05,42.65,
HLA-B27,4089090,CDM,302,RC,86812,HCPCS,Outpatient,,,206.8,124.08,,91.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.76,70,,,percent of total billed charges,70% of total billed charges,155.1,75,,,percent of total billed charges,75% of total billed charges,46.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.33,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,158.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,93.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,28.67,100,,,Fee Schedule,100% of UHC Fee Schedule,144.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.36,230,,,Fee Schedule,230% of CMS OPPS Rate,99.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,186.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,100,,,Fee Schedule,100% of CMS OPPS Rate,25.81,186.12,
ANTI-LEGION PNEUMOPH AB,4089100,CDM,302,RC,86713,HCPCS,Outpatient,,,36.85,22.11,,54.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.8,70,,,percent of total billed charges,70% of total billed charges,27.64,75,,,percent of total billed charges,75% of total billed charges,27.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.55,350,,,Fee Schedule,350% of CMS OPPS Rate,15.6,102,,,Fee Schedule,102% of CMS OPPS Rate,28.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,16.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,17,100,,,Fee Schedule,100% of UHC Fee Schedule,25.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,35.19,230,,,Fee Schedule,230% of CMS OPPS Rate,17.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,33.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,100,,,Fee Schedule,100% of CMS OPPS Rate,15.3,54.16,
ANTI-INFLUENZA VIRUS AB,4089125,CDM,302,RC,86710,HCPCS,Outpatient,,,72.9,43.74,,47.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.42,350,,,Fee Schedule,350% of CMS OPPS Rate,13.82,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,15.06,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,31.16,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,100,,,Fee Schedule,100% of CMS OPPS Rate,13.55,65.61,
THYROGLOBULIN,4089130,CDM,301,RC,84432,HCPCS,Outpatient,,,125.95,75.57,,56.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40.43,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,88.17,70,,,percent of total billed charges,70% of total billed charges,94.46,75,,,percent of total billed charges,75% of total billed charges,28.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.21,350,,,Fee Schedule,350% of CMS OPPS Rate,16.38,102,,,Fee Schedule,102% of CMS OPPS Rate,96.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,56.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,17.85,100,,,Fee Schedule,100% of UHC Fee Schedule,88.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,36.93,230,,,Fee Schedule,230% of CMS OPPS Rate,60.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,113.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.05,113.36,
ROTAVIRUS AG-STOOL,4089150,CDM,306,RC,87425,HCPCS,Outpatient,,,111.6,66.96,,42.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.98,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,21.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.93,350,,,Fee Schedule,350% of CMS OPPS Rate,12.21,102,,,Fee Schedule,102% of CMS OPPS Rate,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,100,,,Fee Schedule,100% of UHC Fee Schedule,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,27.55,230,,,Fee Schedule,230% of CMS OPPS Rate,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100,,,Fee Schedule,100% of CMS OPPS Rate,11.98,100.44,
PRONESTYL (PROCAINAMIDE),4089160,CDM,301,RC,80190,HCPCS,Outpatient,,,158.5,95.1,,212.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,60,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,122.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.95,70,,,percent of total billed charges,70% of total billed charges,118.88,75,,,percent of total billed charges,75% of total billed charges,108,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210,350,,,Fee Schedule,350% of CMS OPPS Rate,61.2,102,,,Fee Schedule,102% of CMS OPPS Rate,121.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,71.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,60,100,,,Fee Schedule,100% of CMS OPPS Rate,54,100,,,Fee Schedule,100% of UHC Fee Schedule,110.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,100,,,Fee Schedule,100% of CMS OPPS Rate,138,230,,,Fee Schedule,230% of CMS OPPS Rate,76.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,60,100,,,Fee Schedule,100% of CMS OPPS Rate,142.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,21.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,60,100,,,Fee Schedule,100% of CMS OPPS Rate,21.2,212.4,
ANTI HERPES II IGG AB,4089220,CDM,302,RC,86694,HCPCS,Outpatient,,,218.5,131.1,,50.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.95,70,,,percent of total billed charges,70% of total billed charges,163.88,75,,,percent of total billed charges,75% of total billed charges,25.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,174.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.36,350,,,Fee Schedule,350% of CMS OPPS Rate,14.67,102,,,Fee Schedule,102% of CMS OPPS Rate,167.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,98.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,152.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,15.99,100,,,Fee Schedule,100% of UHC Fee Schedule,152.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,33.09,230,,,Fee Schedule,230% of CMS OPPS Rate,104.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,196.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,100,,,Fee Schedule,100% of CMS OPPS Rate,14.39,196.65,
HERPES SIMPLEX 2 ABS,4089221,CDM,302,RC,86696,HCPCS,Outpatient,,,240.35,144.21,,68.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges,180.26,75,,,percent of total billed charges,75% of total billed charges,34.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.72,350,,,Fee Schedule,350% of CMS OPPS Rate,19.73,102,,,Fee Schedule,102% of CMS OPPS Rate,183.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,108.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,100,,,Fee Schedule,100% of UHC Fee Schedule,168.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.5,230,,,Fee Schedule,230% of CMS OPPS Rate,115.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,100,,,Fee Schedule,100% of CMS OPPS Rate,19.35,216.32,
CH50 (TOTAL COMPLEMENT),4089230,CDM,302,RC,86162,HCPCS,Outpatient,,,261.25,156.75,,71.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.32,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,51.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.88,70,,,percent of total billed charges,70% of total billed charges,195.94,75,,,percent of total billed charges,75% of total billed charges,36.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.12,350,,,Fee Schedule,350% of CMS OPPS Rate,20.72,102,,,Fee Schedule,102% of CMS OPPS Rate,199.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,117.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,22.58,100,,,Fee Schedule,100% of UHC Fee Schedule,182.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,46.73,230,,,Fee Schedule,230% of CMS OPPS Rate,125.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,235.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,20.32,235.13,
PYRIDOXAL PHOS(VIT B6),4089296,CDM,301,RC,84207,HCPCS,Outpatient,,,117.7,70.62,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,82.39,70,,,percent of total billed charges,70% of total billed charges,88.28,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,94.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,90.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,52.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,31.22,100,,,Fee Schedule,100% of UHC Fee Schedule,82.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,56.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,105.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,17.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,105.93,
VITAMIN D,4089300,CDM,301,RC,82652,HCPCS,Outpatient,,,299.7,179.82,,136.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,96.91,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.79,70,,,percent of total billed charges,70% of total billed charges,224.78,75,,,percent of total billed charges,75% of total billed charges,69.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,239.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.75,350,,,Fee Schedule,350% of CMS OPPS Rate,39.27,102,,,Fee Schedule,102% of CMS OPPS Rate,229.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,134.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,209.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,179.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,42.78,100,,,Fee Schedule,100% of UHC Fee Schedule,209.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,88.55,230,,,Fee Schedule,230% of CMS OPPS Rate,143.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,269.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,38.5,100,,,Fee Schedule,100% of CMS OPPS Rate,20.52,269.73,
STONE ANALYSIS,4089310,CDM,301,RC,82355,HCPCS,Outpatient,,,174.5,104.7,,40.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.15,70,,,percent of total billed charges,70% of total billed charges,130.88,75,,,percent of total billed charges,75% of total billed charges,20.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,139.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.53,350,,,Fee Schedule,350% of CMS OPPS Rate,11.81,102,,,Fee Schedule,102% of CMS OPPS Rate,133.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,78.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,12.86,100,,,Fee Schedule,100% of UHC Fee Schedule,122.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,26.63,230,,,Fee Schedule,230% of CMS OPPS Rate,83.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,157.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,100,,,Fee Schedule,100% of CMS OPPS Rate,11.58,157.05,
SPERM ANTIBODIES,4089325,CDM,309,RC,89325,HCPCS,Outpatient,,,77.32,46.39,,37.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.12,70,,,percent of total billed charges,70% of total billed charges,57.99,75,,,percent of total billed charges,75% of total billed charges,19.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.34,350,,,Fee Schedule,350% of CMS OPPS Rate,10.88,102,,,Fee Schedule,102% of CMS OPPS Rate,59.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,34.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of UHC Fee Schedule,54.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,24.54,230,,,Fee Schedule,230% of CMS OPPS Rate,37.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,69.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,100,,,Fee Schedule,100% of CMS OPPS Rate,10.67,69.59,
Collection of venous blood by venipuncture,4089341,CDM,300,RC,36415,HCPCS,Outpatient,,,18.36,11.02,,30.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,12.85,70,,,percent of total billed charges,70% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.99,350,,,Fee Schedule,350% of CMS OPPS Rate,8.74,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.36,230,,,Fee Schedule,230% of CMS OPPS Rate,8.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,30.33,
ZINC,4089600,CDM,301,RC,84630,HCPCS,Outpatient,,,202.4,121.44,,40.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,141.68,70,,,percent of total billed charges,70% of total billed charges,151.8,75,,,percent of total billed charges,75% of total billed charges,20.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,161.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.86,350,,,Fee Schedule,350% of CMS OPPS Rate,11.61,102,,,Fee Schedule,102% of CMS OPPS Rate,154.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,91.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,12.65,100,,,Fee Schedule,100% of UHC Fee Schedule,141.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,26.19,230,,,Fee Schedule,230% of CMS OPPS Rate,97.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,182.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,100,,,Fee Schedule,100% of CMS OPPS Rate,11.39,182.16,
ANTI MYCOPLASMA PNEUM  AB,4089610,CDM,302,RC,86738,HCPCS,Outpatient,,,181.35,108.81,,46.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,33.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges,136.01,75,,,percent of total billed charges,75% of total billed charges,23.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.34,350,,,Fee Schedule,350% of CMS OPPS Rate,13.5,102,,,Fee Schedule,102% of CMS OPPS Rate,138.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,81.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,14.71,100,,,Fee Schedule,100% of UHC Fee Schedule,126.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,30.45,230,,,Fee Schedule,230% of CMS OPPS Rate,87.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,100,,,Fee Schedule,100% of CMS OPPS Rate,13.24,163.22,
UROBILINOGEN-STOOL,4089615,CDM,301,RC,84577,HCPCS,Outpatient,,,91.5,54.9,,59.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.05,70,,,percent of total billed charges,70% of total billed charges,68.63,75,,,percent of total billed charges,75% of total billed charges,30.24,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,350,,,Fee Schedule,350% of CMS OPPS Rate,17.13,102,,,Fee Schedule,102% of CMS OPPS Rate,70,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,41.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,18.68,100,,,Fee Schedule,100% of UHC Fee Schedule,64.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,230,,,Fee Schedule,230% of CMS OPPS Rate,43.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,82.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,16.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,82.35,
HEMOGLOBIN-PLASMA,4089620,CDM,301,RC,83051,HCPCS,Outpatient,,,80.55,48.33,,25.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges,60.41,75,,,percent of total billed charges,75% of total billed charges,13.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.58,350,,,Fee Schedule,350% of CMS OPPS Rate,7.45,102,,,Fee Schedule,102% of CMS OPPS Rate,61.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,8.13,100,,,Fee Schedule,100% of UHC Fee Schedule,56.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,16.81,230,,,Fee Schedule,230% of CMS OPPS Rate,38.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,72.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7.31,72.5,
CULTURE-VIRUS-MISC SPEC,4089635,CDM,306,RC,87252,HCPCS,Outpatient,,,229.5,137.7,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,160.65,70,,,percent of total billed charges,70% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,183.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,175.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,103.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,28.96,100,,,Fee Schedule,100% of UHC Fee Schedule,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,110.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,206.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,206.55,
SPECIMEN COLLECTION FEE,4089803,CDM,300,RC,C9803,HCPCS,Outpatient,,,70,42,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35,50,,,percent of total billed charges,pays at 50% of total billed charges,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,80.32,
Testing for presence of drug,4090307,CDM,301,RC,80307,HCPCS,Outpatient,,,450,270,,219.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,111.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.49,350,,,Fee Schedule,350% of CMS OPPS Rate,63.38,102,,,Fee Schedule,102% of CMS OPPS Rate,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,64.65,100,,,Fee Schedule,100% of UHC Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.92,230,,,Fee Schedule,230% of CMS OPPS Rate,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,405,
TOX - ALCOHOL BIOMARKERS 1OR2,4090321,CDM,301,RC,80321,HCPCS,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
TOX - ALKALOIDS OTHER,4090323,CDM,301,RC,80323,HCPCS,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
TOX - AMPHETAMINES,4090325,CDM,301,RC,80325,HCPCS,Outpatient,,,199.85,119.91,,,,,,Other,Not Separately reimbursable,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,139.9,70,,,percent of total billed charges,70% of total billed charges,149.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,159.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,179.87,
TOX - ANTIDEPRESSANTS PT. 1,4090333,CDM,300,RC,80333,HCPCS,Outpatient,,,186,111.6,,,,,,Other,Not Separately reimbursable,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,167.4,
TOX - ANTIDEPRESSANTS SEROTONERGIC,4090334,CDM,300,RC,80334,HCPCS,Outpatient,,,206,123.6,,,,,,Other,Not Separately reimbursable,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.2,70,,,percent of total billed charges,70% of total billed charges,154.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,164.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.28,185.4,
TOX - TRICYCLIC ANTIDEPRESSANT,4090336,CDM,300,RC,80336,HCPCS,Outpatient,,,109,65.4,,,,,,Other,Not Separately reimbursable,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.5,50,,,percent of total billed charges,pays at 50% of total billed charges,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,98.1,
TOX - ANTIDEPRESSANTS TCA,4090337,CDM,300,RC,80337,HCPCS,Outpatient,,,109,65.4,,,,,,Other,Not Separately reimbursable,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,98.1,
TOX - ANTIDEPRESSANTS,4090338,CDM,300,RC,80338,HCPCS,Outpatient,,,166,99.6,,,,,,Other,Not Separately reimbursable,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,116.2,70,,,percent of total billed charges,70% of total billed charges,124.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.01,149.4,
TOX - BARBITURATES,4090345,CDM,301,RC,80345,HCPCS,Outpatient,,,147,88.2,,,,,,Other,Not Separately reimbursable,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,132.3,
TOX - BENZODIAZEPINES,4090346,CDM,301,RC,80346,HCPCS,Outpatient,,,49.95,29.97,,,,,,Other,Not Separately reimbursable,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,44.96,
TOX - BUPRENORPHINE,4090348,CDM,301,RC,80348,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - CANNABINOIDS NATURAL,4090349,CDM,301,RC,80349,HCPCS,Outpatient,,,63.13,37.88,,,,,,Other,Not Separately reimbursable,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.19,70,,,percent of total billed charges,70% of total billed charges,47.35,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,50.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,56.82,
TOX - COCAINE,4090353,CDM,301,RC,80353,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - FENTANYL,4090354,CDM,301,RC,80354,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - GABAPENTIN,4090355,CDM,301,RC,80355,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - HEROIN METABOLITE,4090356,CDM,301,RC,80356,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - KETAMINE,4090357,CDM,301,RC,80357,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - METHADONE,4090358,CDM,301,RC,80358,HCPCS,Outpatient,,,94,56.4,,,,,,Other,Not Separately reimbursable,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,84.6,
TOX - METHYLENEDIOXYAMPHETAMINES,4090359,CDM,301,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - METHYLPHENIDATE,4090360,CDM,301,RC,80360,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - OPIATES,4090361,CDM,301,RC,80361,HCPCS,Outpatient,,,105,63,,,,,,Other,Not Separately reimbursable,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,94.5,
TOX - OPIOIDS AND OPIATE ANALOGS 1 - 2 C,4090362,CDM,300,RC,80362,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,144,
TOX - OPIOIDS AND OPIATE ANALOGS,4090363,CDM,301,RC,80363,HCPCS,Outpatient,,,180,108,,,,,,Other,Not Separately reimbursable,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126,70,,,percent of total billed charges,70% of total billed charges,135,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.21,162,
TOX - OPIOIDS AND OPIATE ANALOGS 5 OR MO,4090364,CDM,300,RC,80364,HCPCS,Outpatient,,,200,120,,,,,,Other,Not Separately reimbursable,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,180,
TOX - OXYCODONE,4090365,CDM,301,RC,80365,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,60.3,
TOX - PREGABALIN,4090366,CDM,301,RC,80366,HCPCS,Outpatient,,,50,30,,,,,,Other,Not Separately reimbursable,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,45,
TOX - PROPOXYPHENE,4090367,CDM,301,RC,80367,HCPCS,Outpatient,,,95,57,,,,,,Other,Not Separately reimbursable,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.5,70,,,percent of total billed charges,70% of total billed charges,71.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,85.5,
TOX - SLEEP AIDS,4090368,CDM,301,RC,80368,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
"TOX - RELAXANTS, SKELETAL MUSCLE",4090369,CDM,301,RC,80369,HCPCS,Outpatient,,,175,105,,,,,,Other,Not Separately reimbursable,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.5,70,,,percent of total billed charges,70% of total billed charges,131.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,157.5,
TOX -RELAXANTS SKELETAL MUSCLE 3 OR MORE,4090370,CDM,301,RC,80370,HCPCS,Outpatient,,,128,76.8,,,,,,Other,Not Separately reimbursable,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,115.2,
"TOX - STIMULANTS, SYNTHETIC",4090371,CDM,301,RC,80371,HCPCS,Outpatient,,,128,76.8,,,,,,Other,Not Separately reimbursable,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,115.2,
TOX - TAPENTADOL,4090372,CDM,301,RC,80372,HCPCS,Outpatient,,,149,89.4,,,,,,Other,Not Separately reimbursable,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,134.1,
TOX - TRAMADOL,4090373,CDM,301,RC,80373,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - DRUG TEST 1-7 CLASSES,4090480,CDM,300,RC,G0480,HCPCS,Outpatient,,,963.13,577.88,,405.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,88.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,674.19,70,,,percent of total billed charges,70% of total billed charges,722.35,75,,,percent of total billed charges,75% of total billed charges,205.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,770.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,400.5,350,,,Fee Schedule,350% of CMS OPPS Rate,116.71,102,,,Fee Schedule,102% of CMS OPPS Rate,736.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,433.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,674.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,577.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,102.99,100,,,Fee Schedule,100% of UHC Fee Schedule,674.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,263.18,230,,,Fee Schedule,230% of CMS OPPS Rate,462.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,866.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,88.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.57,866.82,
TOX - DRUG TEST 8-14 CLASSES,4090481,CDM,300,RC,G0481,HCPCS,Outpatient,,,1204.93,722.96,,554.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,121.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,156.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,156.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,319.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,843.45,70,,,percent of total billed charges,70% of total billed charges,903.7,75,,,percent of total billed charges,75% of total billed charges,281.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,963.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,548.06,350,,,Fee Schedule,350% of CMS OPPS Rate,159.72,102,,,Fee Schedule,102% of CMS OPPS Rate,921.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,542.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,843.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,722.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,140.93,100,,,Fee Schedule,100% of UHC Fee Schedule,843.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,360.15,230,,,Fee Schedule,230% of CMS OPPS Rate,578.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,121.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,156.59,100,,,Fee Schedule,100% of CMS OPPS Rate,121.2,1084.44,
TOX - DRUG TEST 15-21 CLASSES,4090482,CDM,300,RC,G0482,HCPCS,Outpatient,,,1996.93,1198.16,,703.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,198.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,405.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1397.85,70,,,percent of total billed charges,70% of total billed charges,1497.7,75,,,percent of total billed charges,75% of total billed charges,357.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1597.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,695.59,350,,,Fee Schedule,350% of CMS OPPS Rate,202.71,102,,,Fee Schedule,102% of CMS OPPS Rate,1527.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,898.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1397.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1198.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,178.87,100,,,Fee Schedule,100% of UHC Fee Schedule,1397.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,457.1,230,,,Fee Schedule,230% of CMS OPPS Rate,958.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1797.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,198.74,100,,,Fee Schedule,100% of CMS OPPS Rate,178.87,1797.24,
TOX - DRUG TEST 22 OR MORE CLASSES,4090483,CDM,300,RC,G0483,HCPCS,Outpatient,,,2897.93,1738.76,,874.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,246.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,503.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2028.55,70,,,percent of total billed charges,70% of total billed charges,2173.45,75,,,percent of total billed charges,75% of total billed charges,444.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2318.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,864.22,350,,,Fee Schedule,350% of CMS OPPS Rate,251.85,102,,,Fee Schedule,102% of CMS OPPS Rate,2216.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,499.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2028.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1738.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,222.23,100,,,Fee Schedule,100% of UHC Fee Schedule,2028.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,567.91,230,,,Fee Schedule,230% of CMS OPPS Rate,1391.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2608.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,454.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,246.92,100,,,Fee Schedule,100% of CMS OPPS Rate,222.23,2608.14,
TOX - SPECIMEN VALIDITY 3,4091005,CDM,300,RC,81005,HCPCS,Outpatient,,,6,3.6,,7.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.17,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,4.2,70,,,percent of total billed charges,70% of total billed charges,4.5,75,,,percent of total billed charges,75% of total billed charges,3.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.59,350,,,Fee Schedule,350% of CMS OPPS Rate,2.21,102,,,Fee Schedule,102% of CMS OPPS Rate,4.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.4,100,,,Fee Schedule,100% of UHC Fee Schedule,4.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,4.99,230,,,Fee Schedule,230% of CMS OPPS Rate,2.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,5.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,7.68,
Test to measure creatinine in the urine,4092570,CDM,300,RC,82570,HCPCS,Outpatient,,,14,8.4,,18.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,9.8,70,,,percent of total billed charges,70% of total billed charges,10.5,75,,,percent of total billed charges,75% of total billed charges,9.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.13,350,,,Fee Schedule,350% of CMS OPPS Rate,5.28,102,,,Fee Schedule,102% of CMS OPPS Rate,10.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,9.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,230,,,Fee Schedule,230% of CMS OPPS Rate,6.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,18.33,
TOX - SPECIMEN VALIDITY 1,4093986,CDM,300,RC,83986,HCPCS,Outpatient,,,10,6,,12.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,7,70,,,percent of total billed charges,70% of total billed charges,7.5,75,,,percent of total billed charges,75% of total billed charges,6.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.53,350,,,Fee Schedule,350% of CMS OPPS Rate,3.65,102,,,Fee Schedule,102% of CMS OPPS Rate,7.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.98,100,,,Fee Schedule,100% of UHC Fee Schedule,7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,230,,,Fee Schedule,230% of CMS OPPS Rate,4.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3.58,12.67,
TOX - PHENCYCLIDINE PCP,4093992,CDM,301,RC,83992,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,100,,,Fee Schedule,100% of UHC Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,58.5,
TOX - BARBITURATES,4096324E,CDM,301,RC,80345,HCPCS,Outpatient,,,147,88.2,,,,,,Other,Not Separately reimbursable,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,132.3,
TOX - OPIATES,4096324E,CDM,301,RC,80361,HCPCS,Outpatient,,,105,63,,,,,,Other,Not Separately reimbursable,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,94.5,
TOX - METHADONE,4096324E,CDM,301,RC,80358,HCPCS,Outpatient,,,94,56.4,,,,,,Other,Not Separately reimbursable,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,84.6,
TOX - FENTANYL,4096324E,CDM,301,RC,80354,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - TAPENTADOL,4096324E,CDM,301,RC,80372,HCPCS,Outpatient,,,149,89.4,,,,,,Other,Not Separately reimbursable,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,134.1,
TOX - OXYCODONE,4096324E,CDM,301,RC,80365,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,60.3,
TOX - METHYLENEDIOXYAMPHETAMINES,4096324E,CDM,301,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - HEROIN METABOLITE,4096324E,CDM,301,RC,80356,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - OPIOIDS AND OPIATE ANALOGS,4096324E,CDM,301,RC,80363,HCPCS,Outpatient,,,180,108,,,,,,Other,Not Separately reimbursable,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126,70,,,percent of total billed charges,70% of total billed charges,135,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.21,162,
"TOX - RELAXANTS, SKELETAL MUSCLE",4096324E,CDM,301,RC,80369,HCPCS,Outpatient,,,175,105,,,,,,Other,Not Separately reimbursable,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.5,70,,,percent of total billed charges,70% of total billed charges,131.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,157.5,
TOX - BUPRENORPHINE,4096324E,CDM,301,RC,80348,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - BENZODIAZEPINES,4096324E,CDM,301,RC,80346,HCPCS,Outpatient,,,49.95,29.97,,,,,,Other,Not Separately reimbursable,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,44.96,
TOX - AMPHETAMINES,4096324E,CDM,301,RC,80325,HCPCS,Outpatient,,,199.85,119.91,,,,,,Other,Not Separately reimbursable,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,139.9,70,,,percent of total billed charges,70% of total billed charges,149.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,159.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,179.87,
TOX - COCAINE,4096324E,CDM,301,RC,80353,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - TRAMADOL,4096324E,CDM,301,RC,80373,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - PHENCYCLIDINE PCP,4096324E,CDM,301,RC,83992,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,100,,,Fee Schedule,100% of UHC Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,58.5,
TOX - TRAMADOL,4096326E,CDM,301,RC,80373,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - OPIATES,4096326E,CDM,301,RC,80361,HCPCS,Outpatient,,,105,63,,,,,,Other,Not Separately reimbursable,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,94.5,
TOX - PHENCYCLIDINE PCP,4096326E,CDM,301,RC,83992,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,100,,,Fee Schedule,100% of UHC Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,58.5,
TOX - ANTIDEPRESSANTS,4096326E,CDM,300,RC,80338,HCPCS,Outpatient,,,166,99.6,,,,,,Other,Not Separately reimbursable,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,116.2,70,,,percent of total billed charges,70% of total billed charges,124.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,132.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.01,149.4,
TOX - CANNABINOIDS NATURAL,4096326E,CDM,301,RC,80349,HCPCS,Outpatient,,,63.13,37.88,,,,,,Other,Not Separately reimbursable,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.19,70,,,percent of total billed charges,70% of total billed charges,47.35,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,50.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,56.82,
TOX - BARBITURATES,4096326E,CDM,301,RC,80345,HCPCS,Outpatient,,,147,88.2,,,,,,Other,Not Separately reimbursable,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,132.3,
TOX - PREGABALIN,4096326E,CDM,301,RC,80366,HCPCS,Outpatient,,,50,30,,,,,,Other,Not Separately reimbursable,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,45,
TOX - METHYLPHENIDATE,4096326E,CDM,301,RC,80360,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - KETAMINE,4096326E,CDM,301,RC,80357,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - ALCOHOL BIOMARKERS 1OR2,4096326E,CDM,301,RC,80321,HCPCS,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
"TOX - STIMULANTS, SYNTHETIC",4096326E,CDM,301,RC,80371,HCPCS,Outpatient,,,128,76.8,,,,,,Other,Not Separately reimbursable,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,115.2,
TOX - TAPENTADOL,4096326E,CDM,301,RC,80372,HCPCS,Outpatient,,,149,89.4,,,,,,Other,Not Separately reimbursable,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,134.1,
TOX - OXYCODONE,4096326E,CDM,301,RC,80365,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,60.3,
TOX - METHYLENEDIOXYAMPHETAMINES,4096326E,CDM,301,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - HEROIN METABOLITE,4096326E,CDM,301,RC,80356,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - FENTANYL,4096326E,CDM,301,RC,80354,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - OPIOIDS AND OPIATE ANALOGS,4096326E,CDM,301,RC,80363,HCPCS,Outpatient,,,180,108,,,,,,Other,Not Separately reimbursable,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126,70,,,percent of total billed charges,70% of total billed charges,135,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.21,162,
TOX -RELAXANTS SKELETAL MUSCLE 3 OR MORE,4096326E,CDM,301,RC,80370,HCPCS,Outpatient,,,128,76.8,,,,,,Other,Not Separately reimbursable,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,115.2,
TOX - BENZODIAZEPINES,4096326E,CDM,301,RC,80346,HCPCS,Outpatient,,,49.95,29.97,,,,,,Other,Not Separately reimbursable,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,44.96,
TOX - AMPHETAMINES,4096326E,CDM,301,RC,80325,HCPCS,Outpatient,,,199.85,119.91,,,,,,Other,Not Separately reimbursable,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,139.9,70,,,percent of total billed charges,70% of total billed charges,149.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,159.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,179.87,
TOX - ALKALOIDS OTHER,4096326E,CDM,301,RC,80323,HCPCS,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
TOX - METHADONE,4096326E,CDM,301,RC,80358,HCPCS,Outpatient,,,94,56.4,,,,,,Other,Not Separately reimbursable,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,84.6,
TOX - SLEEP AIDS,4096326E,CDM,301,RC,80368,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - GABAPENTIN,4096326E,CDM,301,RC,80355,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - COCAINE,4096326E,CDM,301,RC,80353,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - BUPRENORPHINE,4096326E,CDM,301,RC,80348,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - TRICYCLIC ANTIDEPRESSANT,4096326E,CDM,300,RC,80336,HCPCS,Outpatient,,,109,65.4,,,,,,Other,Not Separately reimbursable,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.5,50,,,percent of total billed charges,pays at 50% of total billed charges,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,98.1,
TOX - ANTIDEPRESSANTS PT. 1,4096326E,CDM,300,RC,80333,HCPCS,Outpatient,,,186,111.6,,,,,,Other,Not Separately reimbursable,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,167.4,
TOX - OPIATES,4096327E,CDM,301,RC,80361,HCPCS,Outpatient,,,105,63,,,,,,Other,Not Separately reimbursable,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,94.5,
TOX - CANNABINOIDS NATURAL,4096327E,CDM,301,RC,80349,HCPCS,Outpatient,,,63.13,37.88,,,,,,Other,Not Separately reimbursable,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.19,70,,,percent of total billed charges,70% of total billed charges,47.35,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,50.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,56.82,
TOX - BUPRENORPHINE,4096327E,CDM,301,RC,80348,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - PHENCYCLIDINE PCP,4096327E,CDM,301,RC,83992,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,100,,,Fee Schedule,100% of UHC Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,58.5,
TOX - BARBITURATES,4096327E,CDM,301,RC,80345,HCPCS,Outpatient,,,147,88.2,,,,,,Other,Not Separately reimbursable,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,132.3,
TOX - OXYCODONE,4096327E,CDM,301,RC,80365,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,60.3,
TOX - METHADONE,4096327E,CDM,301,RC,80358,HCPCS,Outpatient,,,94,56.4,,,,,,Other,Not Separately reimbursable,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,84.6,
TOX - COCAINE,4096327E,CDM,301,RC,80353,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - BENZODIAZEPINES,4096327E,CDM,301,RC,80346,HCPCS,Outpatient,,,49.95,29.97,,,,,,Other,Not Separately reimbursable,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,44.96,
TOX - AMPHETAMINES,4096327E,CDM,301,RC,80325,HCPCS,Outpatient,,,199.85,119.91,,,,,,Other,Not Separately reimbursable,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,139.9,70,,,percent of total billed charges,70% of total billed charges,149.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,159.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,179.87,
TOX - METHYLENEDIOXYAMPHETAMINES,4096327E,CDM,301,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - TRICYCLIC ANTIDEPRESSANT,4096327E,CDM,300,RC,80336,HCPCS,Outpatient,,,109,65.4,,,,,,Other,Not Separately reimbursable,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.5,50,,,percent of total billed charges,pays at 50% of total billed charges,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.08,98.1,
TOX - COCAINE,4096328E,CDM,301,RC,80353,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - OPIATES,4096328E,CDM,301,RC,80361,HCPCS,Outpatient,,,105,63,,,,,,Other,Not Separately reimbursable,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.5,70,,,percent of total billed charges,70% of total billed charges,78.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,94.5,
TOX - ALKALOIDS OTHER,4096328E,CDM,301,RC,80323,HCPCS,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
TOX - SLEEP AIDS,4096328E,CDM,301,RC,80368,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - BARBITURATES,4096328E,CDM,301,RC,80345,HCPCS,Outpatient,,,147,88.2,,,,,,Other,Not Separately reimbursable,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.9,70,,,percent of total billed charges,70% of total billed charges,110.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,117.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.03,132.3,
TOX - CANNABINOIDS NATURAL,4096328E,CDM,301,RC,80349,HCPCS,Outpatient,,,63.13,37.88,,,,,,Other,Not Separately reimbursable,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.19,70,,,percent of total billed charges,70% of total billed charges,47.35,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,50.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,56.82,
TOX - PREGABALIN,4096328E,CDM,301,RC,80366,HCPCS,Outpatient,,,50,30,,,,,,Other,Not Separately reimbursable,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,45,
TOX - KETAMINE,4096328E,CDM,301,RC,80357,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - GABAPENTIN,4096328E,CDM,301,RC,80355,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,67.5,
TOX - ALCOHOL BIOMARKERS 1OR2,4096328E,CDM,301,RC,80321,HCPCS,Outpatient,,,108,64.8,,,,,,Other,Not Separately reimbursable,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.6,70,,,percent of total billed charges,70% of total billed charges,81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,86.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.92,97.2,
"TOX - STIMULANTS, SYNTHETIC",4096328E,CDM,301,RC,80371,HCPCS,Outpatient,,,128,76.8,,,,,,Other,Not Separately reimbursable,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,89.6,70,,,percent of total billed charges,70% of total billed charges,96,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,102.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.06,115.2,
TOX - TRAMADOL,4096328E,CDM,301,RC,80373,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
TOX - TAPENTADOL,4096328E,CDM,301,RC,80372,HCPCS,Outpatient,,,149,89.4,,,,,,Other,Not Separately reimbursable,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.35,134.1,
TOX - OXYCODONE,4096328E,CDM,301,RC,80365,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.5,60.3,
TOX - METHYLENEDIOXYAMPHETAMINES,4096328E,CDM,301,RC,80359,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - HEROIN METABOLITE,4096328E,CDM,301,RC,80356,HCPCS,Outpatient,,,70,42,,,,,,Other,Not Separately reimbursable,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,49,70,,,percent of total billed charges,70% of total billed charges,52.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.97,63,
TOX - OPIOIDS AND OPIATE ANALOGS,4096328E,CDM,301,RC,80363,HCPCS,Outpatient,,,180,108,,,,,,Other,Not Separately reimbursable,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126,70,,,percent of total billed charges,70% of total billed charges,135,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.21,162,
"TOX - RELAXANTS, SKELETAL MUSCLE",4096328E,CDM,301,RC,80369,HCPCS,Outpatient,,,175,105,,,,,,Other,Not Separately reimbursable,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.5,70,,,percent of total billed charges,70% of total billed charges,131.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,140,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,157.5,
TOX - BUPRENORPHINE,4096328E,CDM,301,RC,80348,HCPCS,Outpatient,,,100,60,,,,,,Other,Not Separately reimbursable,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,90,
TOX - BENZODIAZEPINES,4096328E,CDM,301,RC,80346,HCPCS,Outpatient,,,49.95,29.97,,,,,,Other,Not Separately reimbursable,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,34.97,70,,,percent of total billed charges,70% of total billed charges,37.46,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,39.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.83,44.96,
TOX - AMPHETAMINES,4096328E,CDM,301,RC,80325,HCPCS,Outpatient,,,199.85,119.91,,,,,,Other,Not Separately reimbursable,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,139.9,70,,,percent of total billed charges,70% of total billed charges,149.89,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,159.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,179.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,179.87,
TOX - METHADONE,4096328E,CDM,301,RC,80358,HCPCS,Outpatient,,,94,56.4,,,,,,Other,Not Separately reimbursable,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.8,70,,,percent of total billed charges,70% of total billed charges,70.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,75.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.73,84.6,
TOX - PHENCYCLIDINE PCP,4096328E,CDM,301,RC,83992,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.88,100,,,Fee Schedule,100% of UHC Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,18.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.92,58.5,
TOX - FENTANYL,4096328E,CDM,301,RC,80354,HCPCS,Outpatient,,,65,39,,,,,,Other,Not Separately reimbursable,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.5,70,,,percent of total billed charges,70% of total billed charges,48.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,58.5,
Testing for presence of drug,4096328E,CDM,301,RC,80307,HCPCS,Outpatient,,,450,270,,219.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.14,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,111.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.49,350,,,Fee Schedule,350% of CMS OPPS Rate,63.38,102,,,Fee Schedule,102% of CMS OPPS Rate,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,64.65,100,,,Fee Schedule,100% of UHC Fee Schedule,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,142.92,230,,,Fee Schedule,230% of CMS OPPS Rate,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,405,
FETAL HGB SCREENING TEST,4100001,CDM,305,RC,85461,HCPCS,Outpatient,,,58.73,35.24,,33.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.08,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.11,70,,,percent of total billed charges,70% of total billed charges,44.05,75,,,percent of total billed charges,75% of total billed charges,16.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.76,350,,,Fee Schedule,350% of CMS OPPS Rate,9.54,102,,,Fee Schedule,102% of CMS OPPS Rate,44.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,26.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.42,100,,,Fee Schedule,100% of UHC Fee Schedule,41.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.52,230,,,Fee Schedule,230% of CMS OPPS Rate,28.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,52.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,9.36,100,,,Fee Schedule,100% of CMS OPPS Rate,3.8,52.86,
"FETAL HGB STAIN, BLOOD",4105460,CDM,305,RC,85460,HCPCS,Outpatient,,,424.35,254.61,,27.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.69,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,297.05,70,,,percent of total billed charges,70% of total billed charges,318.26,75,,,percent of total billed charges,75% of total billed charges,13.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,339.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.05,350,,,Fee Schedule,350% of CMS OPPS Rate,7.88,102,,,Fee Schedule,102% of CMS OPPS Rate,324.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,190.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,297.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8.6,100,,,Fee Schedule,100% of UHC Fee Schedule,297.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,17.77,230,,,Fee Schedule,230% of CMS OPPS Rate,203.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,381.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.69,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5.69,381.92,
"COLD AGGLUTININS, SERUM",4106006,CDM,302,RC,86156,HCPCS,Outpatient,,,69.75,41.85,,28.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.07,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges,52.31,75,,,percent of total billed charges,75% of total billed charges,14.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.24,350,,,Fee Schedule,350% of CMS OPPS Rate,8.23,102,,,Fee Schedule,102% of CMS OPPS Rate,53.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7.44,100,,,Fee Schedule,100% of UHC Fee Schedule,48.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,18.56,230,,,Fee Schedule,230% of CMS OPPS Rate,33.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,7.44,62.78,
"COLD AGGLUTININ, TITER",4106007,CDM,302,RC,86157,HCPCS,Outpatient,,,89.5,53.7,,28.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.06,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.65,70,,,percent of total billed charges,70% of total billed charges,67.13,75,,,percent of total billed charges,75% of total billed charges,14.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.21,350,,,Fee Schedule,350% of CMS OPPS Rate,8.22,102,,,Fee Schedule,102% of CMS OPPS Rate,68.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,40.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.96,100,,,Fee Schedule,100% of UHC Fee Schedule,62.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,18.53,230,,,Fee Schedule,230% of CMS OPPS Rate,42.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,80.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,100,,,Fee Schedule,100% of CMS OPPS Rate,8.06,80.55,
ANTIBODY TITER,4106008,CDM,302,RC,86886,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.75,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,506.06,
ANTIBODY IDENTIFICATION,4106024,CDM,302,RC,86870,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.86,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,43.86,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,43.86,1043.05,
"AHG (COOMBS), DIRECT, BLD",4106031,CDM,302,RC,86880,HCPCS,Outpatient,,,90,54,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.99,100,,,Fee Schedule,100% of UHC Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5.39,184.98,
Blood test to screen for antibodies that could harm red blood cells,4106033,CDM,302,RC,86850,HCPCS,Outpatient,,,134,80.4,,161.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.92,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges,100.5,75,,,percent of total billed charges,75% of total billed charges,82.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,107.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,159.53,350,,,Fee Schedule,350% of CMS OPPS Rate,46.49,103,,,Fee Schedule,103% of CMS OPPS Rate,102.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,8.79,100,,,Fee Schedule,100% of UHC Fee Schedule,93.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,100,,,Fee Schedule,100% of CMS OPPS Rate,64.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,120.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,45.58,100,,,Fee Schedule,100% of CMS OPPS Rate,6.74,161.36,
AUTOLOGOUS UNIT HANDLING,4106051,CDM,300,RC,86890,HCPCS,Outpatient,,,236.5,141.9,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,165.55,70,,,percent of total billed charges,70% of total billed charges,177.38,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,189.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,180.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,106.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,165.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,165.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,113.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,506.06,
TRANSFUSION REACTION INVEST,4106078,CDM,300,RC,86078,HCPCS,Outpatient,,,197.2,118.32,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,138.04,70,,,percent of total billed charges,70% of total billed charges,147.9,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,157.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,150.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,88.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,138.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,94.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,177.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,506.06,
"ANTIGEN TYPE, DONOR BLOOD",4106095,CDM,302,RC,86902,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.97,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,5.72,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.97,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,4.97,1043.05,
"RHO IMMUNE GLOBULIN, SER",4106115,CDM,636,RC,J2788,HCPCS,Outpatient,,,230,138,,,,,,Other,Not Separately reimbursable,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,50,,,percent of total billed charges,pays at 50% of total billed charges,161,70,,,percent of total billed charges,70% of total billed charges,172.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.04,207,
RHO IMMUNE GLOBULIN INJECTION,4106116,CDM,636,RC,J2790,HCPCS,Outpatient,,,230,138,,,,,,Other,Not Separately reimbursable,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,50,,,percent of total billed charges,pays at 50% of total billed charges,161,70,,,percent of total billed charges,70% of total billed charges,172.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,184,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.04,207,
FROZEN CELL PROCESSING,4106265,CDM,302,RC,86930,HCPCS,Outpatient,,,202.5,121.5,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.01,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,141.75,70,,,percent of total billed charges,70% of total billed charges,151.88,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,202.5,103,,,Fee Schedule,103% of CMS OPPS Rate,154.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,91.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,141.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,202.5,100,,,Fee Schedule,100% of CMS OPPS Rate,182.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.01,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,1043.05,
BLOOD TYPE - ABO,4106902,CDM,302,RC,86900,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,3.32,100,,,Fee Schedule,100% of UHC Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2.99,373.66,
BLOOD TYPE - RH,4106903,CDM,302,RC,86901,HCPCS,Outpatient,,,90,54,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3.32,100,,,Fee Schedule,100% of UHC Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2.99,109.29,
UBS (RH PHENOTYPE),4106906,CDM,302,RC,86906,HCPCS,Outpatient,,,115.5,69.3,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.75,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of UHC Fee Schedule,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.75,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,7.75,109.29,
XM UNIT EA - IMMED SPIN,4106920,CDM,302,RC,86920,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,506.06,
XM UNIT EA - INCUBATION,4106921,CDM,302,RC,86921,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,506.06,
XM UNIT EA - ANTIGLOBULIN,4106922,CDM,302,RC,86922,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,48.94,506.06,
UBS (ABSORPTION),4106978,CDM,302,RC,86978,HCPCS,Outpatient,,,175.05,105.03,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.54,70,,,percent of total billed charges,70% of total billed charges,131.29,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,133.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,78.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,157.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10.6,157.55,
"RBC ANTIGENS, OTHER",4106995,CDM,302,RC,86905,HCPCS,Outpatient,,,767,460.2,,1043.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,294.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges,575.25,75,,,percent of total billed charges,75% of total billed charges,530.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,613.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1031.26,350,,,Fee Schedule,350% of CMS OPPS Rate,300.54,103,,,Fee Schedule,103% of CMS OPPS Rate,586.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,345.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,460.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,4.26,100,,,Fee Schedule,100% of UHC Fee Schedule,536.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,368.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,294.64,100,,,Fee Schedule,100% of CMS OPPS Rate,3.83,1043.05,
BLOOD TYPE - RH,4107000,CDM,302,RC,86901,HCPCS,Outpatient,,,90,54,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3.32,100,,,Fee Schedule,100% of UHC Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2.99,109.29,
BLOOD TYPE - ABO,4107000,CDM,302,RC,86900,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,3.32,100,,,Fee Schedule,100% of UHC Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2.99,373.66,
BLOOD PRODUCT SPLIT RC VO,4107001,CDM,390,RC,P9011,HCPCS,Outpatient,,,129,77.4,,492.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,129,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,90.3,70,,,percent of total billed charges,70% of total billed charges,96.75,75,,,percent of total billed charges,75% of total billed charges,250.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,103.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,486.67,350,,,Fee Schedule,350% of CMS OPPS Rate,129,103,,,Fee Schedule,103% of CMS OPPS Rate,98.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,58.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,90.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,319.81,100,,,Fee Schedule,100% of CMS OPPS Rate,61.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,129,100,,,Fee Schedule,100% of CMS OPPS Rate,116.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.21,1373,
BLOOD PRODUCT SPLIT RC VO,4107002,CDM,390,RC,P9011,HCPCS,Outpatient,,,174.6,104.76,,492.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.22,70,,,percent of total billed charges,70% of total billed charges,130.95,75,,,percent of total billed charges,75% of total billed charges,250.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,139.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,486.67,350,,,Fee Schedule,350% of CMS OPPS Rate,141.83,103,,,Fee Schedule,103% of CMS OPPS Rate,133.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,78.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,122.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,319.81,100,,,Fee Schedule,100% of CMS OPPS Rate,83.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,157.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,27.36,1373,
BLOOD PRODUCT SPLIT FFP V,4107004,CDM,390,RC,P9011,HCPCS,Outpatient,,,103.95,62.37,,492.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,103.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.77,70,,,percent of total billed charges,70% of total billed charges,77.96,75,,,percent of total billed charges,75% of total billed charges,250.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,83.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,486.67,350,,,Fee Schedule,350% of CMS OPPS Rate,103.95,103,,,Fee Schedule,103% of CMS OPPS Rate,79.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,72.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,319.81,100,,,Fee Schedule,100% of CMS OPPS Rate,49.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,103.95,100,,,Fee Schedule,100% of CMS OPPS Rate,93.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,16.29,1373,
BLOOD PRODUCT SPL PHER VO,4107007,CDM,390,RC,P9011,HCPCS,Outpatient,,,441.45,264.87,,492.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,309.02,70,,,percent of total billed charges,70% of total billed charges,331.09,75,,,percent of total billed charges,75% of total billed charges,250.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,353.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,486.67,350,,,Fee Schedule,350% of CMS OPPS Rate,141.83,103,,,Fee Schedule,103% of CMS OPPS Rate,337.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,198.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,309.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,309.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,319.81,100,,,Fee Schedule,100% of CMS OPPS Rate,211.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,397.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,69.18,1373,
XM UNIT EA - ANTIGLOBULIN,4107010,CDM,302,RC,86922,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,48.94,506.06,
XM UNIT EA - IMMED SPIN,4107010,CDM,302,RC,86920,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,506.06,
XM UNIT EA - ANTIGLOBULIN,4107011,CDM,302,RC,86922,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,48.94,506.06,
XM UNIT EA - INCUBATION,4107011,CDM,302,RC,86921,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,506.06,
XM UNIT EA - IMMED SPIN,4107011,CDM,302,RC,86920,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,51.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,51.38,506.06,
CRYOPRECIPITATE EACH UNIT,4107012,CDM,390,RC,P9012,HCPCS,Outpatient,,,180.45,108.27,,263.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges,135.34,75,,,percent of total billed charges,75% of total billed charges,133.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,144.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.36,350,,,Fee Schedule,350% of CMS OPPS Rate,75.87,103,,,Fee Schedule,103% of CMS OPPS Rate,138.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,81.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate,86.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,1373,
"PLATELET PHERESIS,LR",4109019,CDM,390,RC,P9035,HCPCS,Outpatient,,,928,556.8,,1719.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,485.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,972.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,649.6,70,,,percent of total billed charges,70% of total billed charges,696,75,,,percent of total billed charges,75% of total billed charges,874.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,742.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1699.81,350,,,Fee Schedule,350% of CMS OPPS Rate,495.37,103,,,Fee Schedule,103% of CMS OPPS Rate,709.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,159.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,417.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,649.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,556.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,649.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1117.01,100,,,Fee Schedule,100% of CMS OPPS Rate,445.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,835.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,145.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,485.66,100,,,Fee Schedule,100% of CMS OPPS Rate,145.42,1719.23,
BLOOD-SPLIT UNIT PROC,4109026,CDM,302,RC,86985,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,15.18,506.06,
"RBC, LEUKOREDUCED, EA",4109030,CDM,390,RC,P9016,HCPCS,Outpatient,,,365,219,,669.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,374.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,255.5,70,,,percent of total billed charges,70% of total billed charges,273.75,75,,,percent of total billed charges,75% of total billed charges,340.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,662.23,350,,,Fee Schedule,350% of CMS OPPS Rate,192.99,103,,,Fee Schedule,103% of CMS OPPS Rate,279.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,164.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,435.18,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,328.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,57.2,1373,
"PLATELETS, PHER LR IRRAD",4109039,CDM,390,RC,P9037,HCPCS,Outpatient,,,905.4,543.24,,2259.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,638.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1273.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,633.78,70,,,percent of total billed charges,70% of total billed charges,679.05,75,,,percent of total billed charges,75% of total billed charges,1148.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,724.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2233.66,350,,,Fee Schedule,350% of CMS OPPS Rate,650.95,103,,,Fee Schedule,103% of CMS OPPS Rate,692.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,407.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,633.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,543.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,633.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1467.83,100,,,Fee Schedule,100% of CMS OPPS Rate,434.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,814.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,638.19,100,,,Fee Schedule,100% of CMS OPPS Rate,141.88,2259.19,
RBC SPLIT PRODUCT,4109047,CDM,390,RC,P9011,HCPCS,Outpatient,,,155,93,,492.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,139.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,209.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,108.5,70,,,percent of total billed charges,70% of total billed charges,116.25,75,,,percent of total billed charges,75% of total billed charges,250.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,486.67,350,,,Fee Schedule,350% of CMS OPPS Rate,141.83,103,,,Fee Schedule,103% of CMS OPPS Rate,118.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,69.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,108.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,319.81,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,139.05,100,,,Fee Schedule,100% of CMS OPPS Rate,24.29,1373,
CRYOPRECIPITATE EACH UNIT,4109048,CDM,390,RC,P9012,HCPCS,Outpatient,,,180.45,108.27,,263.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.32,70,,,percent of total billed charges,70% of total billed charges,135.34,75,,,percent of total billed charges,75% of total billed charges,133.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,144.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,260.36,350,,,Fee Schedule,350% of CMS OPPS Rate,75.87,103,,,Fee Schedule,103% of CMS OPPS Rate,138.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,81.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,126.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate,86.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,162.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,74.39,100,,,Fee Schedule,100% of CMS OPPS Rate,28.28,1373,
PLASMA 1 DONOR W/IN 8 HR,4109049,CDM,390,RC,P9017,HCPCS,Outpatient,,,203.4,122.04,,302.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,147.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,142.38,70,,,percent of total billed charges,70% of total billed charges,152.55,75,,,percent of total billed charges,75% of total billed charges,153.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,162.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,299.14,350,,,Fee Schedule,350% of CMS OPPS Rate,87.17,103,,,Fee Schedule,103% of CMS OPPS Rate,155.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,91.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,142.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,196.58,100,,,Fee Schedule,100% of CMS OPPS Rate,97.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,183.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,85.47,100,,,Fee Schedule,100% of CMS OPPS Rate,31.87,1373,
"AUTO-RBC LR, EA UNIT",4109052,CDM,390,RC,P9016,HCPCS,Outpatient,,,381.6,228.96,,669.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,374.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,267.12,70,,,percent of total billed charges,70% of total billed charges,286.2,75,,,percent of total billed charges,75% of total billed charges,340.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,305.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,662.23,350,,,Fee Schedule,350% of CMS OPPS Rate,192.99,103,,,Fee Schedule,103% of CMS OPPS Rate,291.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,171.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,267.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,228.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,267.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,435.18,100,,,Fee Schedule,100% of CMS OPPS Rate,183.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,343.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,189.21,100,,,Fee Schedule,100% of CMS OPPS Rate,59.8,1373,
FRESH FROZ PLASMA THAW,4109054,CDM,302,RC,86927,HCPCS,Outpatient,,,388,232.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges,291,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,193.89,100,,,Fee Schedule,100% of UHC Fee Schedule,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.94,100,,,Fee Schedule,100% of CMS OPPS Rate,11.05,506.06,
POOLING OF PLATELETS,4109055,CDM,302,RC,86965,HCPCS,Outpatient,,,76.74,46.04,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.13,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,53.72,70,,,percent of total billed charges,70% of total billed charges,57.56,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,76.74,103,,,Fee Schedule,103% of CMS OPPS Rate,58.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,34.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,53.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,36.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.74,100,,,Fee Schedule,100% of CMS OPPS Rate,69.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,15.13,506.06,
"RBC, LR IRRAD EACH",4109057,CDM,390,RC,P9040,HCPCS,Outpatient,,,473,283.8,,917.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,259.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,530.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,331.1,70,,,percent of total billed charges,70% of total billed charges,354.75,75,,,percent of total billed charges,75% of total billed charges,466.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,906.92,350,,,Fee Schedule,350% of CMS OPPS Rate,264.3,103,,,Fee Schedule,103% of CMS OPPS Rate,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,595.97,100,,,Fee Schedule,100% of CMS OPPS Rate,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,259.12,100,,,Fee Schedule,100% of CMS OPPS Rate,74.12,1373,
"CMV-N LR WB/RBC, EA UNIT",4109064,CDM,390,RC,P9051,HCPCS,Outpatient,,,428,256.8,,695.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,196.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,196.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,392.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,299.6,70,,,percent of total billed charges,70% of total billed charges,321,75,,,percent of total billed charges,75% of total billed charges,353.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,687.5,350,,,Fee Schedule,350% of CMS OPPS Rate,200.35,103,,,Fee Schedule,103% of CMS OPPS Rate,327.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,192.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,299.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,451.78,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,385.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,1373,
FFP 8-24HRS OF COLL EA UN,4109066,CDM,390,RC,P9059,HCPCS,Outpatient,,,203.4,122.04,,269.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,151.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,142.38,70,,,percent of total billed charges,70% of total billed charges,152.55,75,,,percent of total billed charges,75% of total billed charges,137.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,162.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.7,350,,,Fee Schedule,350% of CMS OPPS Rate,77.72,103,,,Fee Schedule,103% of CMS OPPS Rate,155.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,91.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,142.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,175.26,100,,,Fee Schedule,100% of CMS OPPS Rate,97.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,183.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.2,100,,,Fee Schedule,100% of CMS OPPS Rate,31.87,1373,
RED BLD CELLS EACH UNIT,4109068,CDM,390,RC,P9021,HCPCS,Outpatient,,,365,219,,479.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,135.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,291.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,255.5,70,,,percent of total billed charges,70% of total billed charges,273.75,75,,,percent of total billed charges,75% of total billed charges,243.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,474.32,350,,,Fee Schedule,350% of CMS OPPS Rate,138.22,103,,,Fee Schedule,103% of CMS OPPS Rate,279.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,164.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,255.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,311.69,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,328.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,135.52,100,,,Fee Schedule,100% of CMS OPPS Rate,57.2,1373,
RED BLD CELLS WASHED EACH UNIT,4109069,CDM,390,RC,P9022,HCPCS,Outpatient,,,347.4,208.44,,1401.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,347.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,783.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,243.18,70,,,percent of total billed charges,70% of total billed charges,260.55,75,,,percent of total billed charges,75% of total billed charges,712.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,277.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1385.23,350,,,Fee Schedule,350% of CMS OPPS Rate,347.4,103,,,Fee Schedule,103% of CMS OPPS Rate,265.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,156.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,243.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,243.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,910.29,100,,,Fee Schedule,100% of CMS OPPS Rate,166.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,347.4,100,,,Fee Schedule,100% of CMS OPPS Rate,312.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,395.78,100,,,Fee Schedule,100% of CMS OPPS Rate,54.44,1401.06,
THERAPEUTIC PHLEBOTOMY,4109195,CDM,940,RC,99195,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,373.66,
"THERAPEUTIC APHER, PLASMA",4109198,CDM,761,RC,36514,HCPCS,Outpatient,,,1273.5,764.1,,4376.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1236.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2491.01,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,955.13,75,,,percent of total billed charges,75% of total billed charges,2225.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1018.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4326.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1260.95,103,,,Fee Schedule,103% of CMS OPPS Rate,974.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,219.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,573.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,891.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,764.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,891.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2843.32,100,,,Fee Schedule,100% of CMS OPPS Rate,611.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,199.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,199.56,4376.25,
"THERAPEUTIC APHERESIS,RBC",4109200,CDM,761,RC,36512,HCPCS,Outpatient,,,1861.5,1116.9,,4376.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1236.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2491.01,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1396.13,75,,,percent of total billed charges,75% of total billed charges,2225.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1489.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4326.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1260.95,103,,,Fee Schedule,103% of CMS OPPS Rate,1424.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,320.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,837.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1303.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1116.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1303.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2843.32,100,,,Fee Schedule,100% of CMS OPPS Rate,893.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,291.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.23,100,,,Fee Schedule,100% of CMS OPPS Rate,291.7,4376.25,
UBS (RBC TREATMENT),4109335,CDM,302,RC,86970,HCPCS,Outpatient,,,134.2,80.52,,109.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,93.94,70,,,percent of total billed charges,70% of total billed charges,100.65,75,,,percent of total billed charges,75% of total billed charges,55.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,107.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.05,350,,,Fee Schedule,350% of CMS OPPS Rate,31.49,103,,,Fee Schedule,103% of CMS OPPS Rate,102.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,60.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,100,,,Fee Schedule,100% of UHC Fee Schedule,93.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,120.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2.76,120.78,
UBS (ELUTION),4109342,CDM,302,RC,86860,HCPCS,Outpatient,,,93,55.8,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.54,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,65.1,70,,,percent of total billed charges,70% of total billed charges,69.75,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,93,103,,,Fee Schedule,103% of CMS OPPS Rate,71.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,41.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,65.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,65.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,93,100,,,Fee Schedule,100% of CMS OPPS Rate,83.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,14.54,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,14.54,506.06,
TILT WITH OR W/O ISUPREL,4111025,CDM,480,RC,93660,HCPCS,Outpatient,,,1744.6,1046.76,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1221.22,70,,,percent of total billed charges,70% of total billed charges,1308.45,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1395.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,1334.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,300.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,785.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1221.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1221.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,837.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1570.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,273.38,1570.14,
DUPLEX SCAN-CAROTID-UNILA,4111061,CDM,920,RC,93882,HCPCS,Outpatient,,,550.4,330.24,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,385.28,70,,,percent of total billed charges,70% of total billed charges,412.8,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,440.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,421.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,247.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,385.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,330.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,340,100,,,Case rate,Pays based on per visit ,385.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,264.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,495.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,86.25,495.36,
Study of vessels on both sides of the head and neck,4111062,CDM,921,RC,93880,HCPCS,Outpatient,,,689.4,413.64,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,482.58,70,,,percent of total billed charges,70% of total billed charges,517.05,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,551.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,527.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,310.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,482.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,413.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,482.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,330.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,620.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,108.03,751.51,
Complete bilateral study of the extremities,4111066,CDM,921,RC,93970,HCPCS,Outpatient,,,734.04,440.42,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,513.83,70,,,percent of total billed charges,70% of total billed charges,550.53,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,587.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,561.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,330.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,513.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,513.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,352.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,660.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,115.02,751.51,
One sided or limited bilateral study,4111091,CDM,921,RC,93971,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
EKG PANEL,4111100,CDM,730,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.05,70,,,percent of total billed charges,70% of total billed charges,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,373,
EKG PANEL,4111101,CDM,730,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.05,70,,,percent of total billed charges,70% of total billed charges,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,373,
EXERCISE STRESS TEST,4111145,CDM,482,RC,93017,HCPCS,Outpatient,,,910.36,546.22,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,637.25,70,,,percent of total billed charges,70% of total billed charges,682.77,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,728.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,696.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,409.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,637.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,546.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1178,100,,,Case rate,Pays based on per visit ,637.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,436.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,819.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,142.65,1178,
PHARMACOLOGICAL STRESS TEST,4111146,CDM,482,RC,93017,HCPCS,Outpatient,,,744.84,446.9,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,521.39,70,,,percent of total billed charges,70% of total billed charges,558.63,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,595.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,569.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,335.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,521.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,446.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1178,100,,,Case rate,Pays based on per visit ,521.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,357.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,670.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,116.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,116.72,1178,
PROV OF ISOTOPE(CARDIOLYT,4111149,CDM,343,RC,A9500,HCPCS,Outpatient,,,481.05,288.63,,86.59,18,,,percent of total billed charges,pays at 18% of total charges,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.53,50,,,percent of total billed charges,pays at 50% of total billed charges,336.74,70,,,percent of total billed charges,70% of total billed charges,360.79,75,,,percent of total billed charges,75% of total billed charges,240.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,481.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.38,481.05,
ECHO - TRANSESOPHAGEAL,4111155,CDM,483,RC,93312,HCPCS,Outpatient,,,1406.88,844.13,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,992.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,984.82,70,,,percent of total billed charges,70% of total billed charges,1055.16,75,,,percent of total billed charges,75% of total billed charges,823.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1125.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.87,350,,,Fee Schedule,350% of CMS OPPS Rate,466.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1076.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,242.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,633.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,984.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,844.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,984.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,675.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1266.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,220.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,220.46,1619.18,
RHYTHM EGC 1-3 LEADS,4111162,CDM,730,RC,93041,HCPCS,Outpatient,,,57.5,34.5,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.25,70,,,percent of total billed charges,70% of total billed charges,43.13,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,43.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,40.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,27.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,51.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,373,
Echo without doppler study,4111163,CDM,731,RC,93307,HCPCS,Outpatient,,,679.84,407.9,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,992.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,475.89,70,,,percent of total billed charges,70% of total billed charges,509.88,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,543.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,520.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,305.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,475.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,407.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,806,100,,,Case rate,Pays based on per visit ,475.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,326.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,611.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,106.53,992.31,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",4111172,CDM,483,RC,93306,HCPCS,Outpatient,,,2105.24,1263.14,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,992.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1473.67,70,,,percent of total billed charges,70% of total billed charges,1578.93,75,,,percent of total billed charges,75% of total billed charges,823.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1684.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.87,350,,,Fee Schedule,350% of CMS OPPS Rate,466.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1610.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,362.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,947.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1473.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1263.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1473.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1894.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,329.89,1894.72,
ECHO - FOLLOWUP,4111175,CDM,483,RC,93308,HCPCS,Outpatient,,,631,378.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,482.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,567.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,98.88,1196,
SIGNAL AVERAGE EKG,4111544,CDM,730,RC,93278,HCPCS,Outpatient,,,426.25,255.75,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,298.38,70,,,percent of total billed charges,70% of total billed charges,319.69,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,341,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,326.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,191.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,298.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,298.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,204.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,383.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,383.63,
24 HR HOLTER CNNT W RECORDING,4111548,CDM,731,RC,93225,HCPCS,Outpatient,,,344.85,206.91,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,241.4,70,,,percent of total billed charges,70% of total billed charges,258.64,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,275.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,263.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,155.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,241.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,806,100,,,Case rate,Pays based on per visit ,241.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,165.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,310.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,54.04,806,
HOLTER MONITOR SCAN ANALYSIS & REPORT,4111549,CDM,731,RC,93226,HCPCS,Outpatient,,,1034.54,620.72,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,724.18,70,,,percent of total billed charges,70% of total billed charges,775.91,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,827.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,791.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,178.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,465.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,724.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,620.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,806,100,,,Case rate,Pays based on per visit ,724.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,496.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,931.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,931.09,
PERF (SPECT) SINGLE,4111669,CDM,343,RC,78451,HCPCS,Outpatient,,,1120.05,672.03,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1120.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,784.04,70,,,percent of total billed charges,70% of total billed charges,840.04,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,896.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1120.05,103,,,Fee Schedule,103% of CMS OPPS Rate,856.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,192.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,504.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,784.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,672.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,425.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,784.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,537.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1120.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1008.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,175.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,175.51,4271.43,
Image of the heart to assess perfusion,4111670,CDM,341,RC,78452,HCPCS,Outpatient,,,3443,2065.8,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2410.1,70,,,percent of total billed charges,70% of total billed charges,2582.25,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,2633.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,593.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2410.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2065.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,2410.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1652.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3098.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,539.52,4271.43,
LT STUDY PSEUD ANEURSYM,4111676,CDM,921,RC,93926,HCPCS,Outpatient,,,474.8,284.88,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,332.36,70,,,percent of total billed charges,70% of total billed charges,356.1,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,379.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,363.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,213.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,227.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,427.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,427.32,
Stress test with echocardiogram,4111835,CDM,483,RC,93350,HCPCS,Outpatient,,,1709.13,1025.48,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,992.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1196.39,70,,,percent of total billed charges,70% of total billed charges,1281.85,75,,,percent of total billed charges,75% of total billed charges,823.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1367.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.87,350,,,Fee Schedule,350% of CMS OPPS Rate,466.54,103,,,Fee Schedule,103% of CMS OPPS Rate,1307.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,769.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1196.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1025.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1196.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,820.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,267.82,1619.18,
ADMINISTRATION ECHO CONTRAST AGENT,4111836,CDM,483,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196,1196,
PROV OF ISOTOPE (MYOVIEW),4111841,CDM,343,RC,A9502,HCPCS,Outpatient,,,553.05,331.83,,99.55,18,,,percent of total billed charges,pays at 18% of total charges,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,276.53,50,,,percent of total billed charges,pays at 50% of total billed charges,387.14,70,,,percent of total billed charges,70% of total billed charges,414.79,75,,,percent of total billed charges,75% of total billed charges,276.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,442.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,331.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,423.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,387.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,331.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,210.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,387.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,553.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,497.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.66,553.05,
PROV OF ISOTOPE(THALLIUM),4111842,CDM,343,RC,A9505,HCPCS,Outpatient,,,481,288.6,,86.58,18,,,percent of total billed charges,pays at 18% of total charges,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,50,,,percent of total billed charges,pays at 50% of total billed charges,336.7,70,,,percent of total billed charges,70% of total billed charges,360.75,75,,,percent of total billed charges,75% of total billed charges,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,481,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.37,481,
DUPLEX SCAN LOWER EXT BIL,4112006,CDM,921,RC,93925,HCPCS,Outpatient,,,754.16,452.5,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,527.91,70,,,percent of total billed charges,70% of total billed charges,565.62,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,603.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,576.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,339.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,527.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,527.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,362,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,678.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,118.18,751.51,
DUPLEX SCAN LWR EXT UNIL,4112007,CDM,921,RC,93926,HCPCS,Outpatient,,,474.8,284.88,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,332.36,70,,,percent of total billed charges,70% of total billed charges,356.1,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,379.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,363.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,213.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,227.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,427.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,427.32,
DUPLEX SCAN UPPER EXT BIL,4112008,CDM,921,RC,93930,HCPCS,Outpatient,,,685.6,411.36,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.92,70,,,percent of total billed charges,70% of total billed charges,514.2,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,524.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,308.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,479.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,329.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,617.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,107.43,751.51,
DUPLEX SCAN UPPR EXT UNIL,4112009,CDM,921,RC,93931,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
CARDIOVERSION,4112010,CDM,480,RC,92960,HCPCS,Outpatient,,,1452,871.2,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges,1089,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1110.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,653.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,696.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,1892.75,
CARDIOPULMONARY RES-CPR,4112011,CDM,482,RC,92950,HCPCS,Outpatient,,,604.08,362.45,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,422.86,70,,,percent of total billed charges,70% of total billed charges,453.06,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,483.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,462.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,271.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,422.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1178,100,,,Case rate,Pays based on per visit ,422.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,289.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,543.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,94.66,1178,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,4113922,CDM,921,RC,93922,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
NONINVASIVE PRODUCTIVITY ONLY,4119998,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
EKG ER PRODUCTIVITY ONLY,4119999E,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
CARDIOLOGY PRODUCTIVITY ONLY,4120001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
REPAIR PM/ICD LEAD-SINGLE,4121009,CDM,481,RC,33218,HCPCS,Outpatient,,,3973.2,2383.92,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2781.24,70,,,percent of total billed charges,70% of total billed charges,2979.9,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3178.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.24,103,,,Fee Schedule,103% of CMS OPPS Rate,3039.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,684.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1787.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2781.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2383.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2781.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1907.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3575.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,622.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,622.6,10784,
PTA VENOUS,4121019,CDM,481,RC,37248,HCPCS,Outpatient,,,5360,3216,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5360,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8812.64,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3752,70,,,percent of total billed charges,70% of total billed charges,4020,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,4100.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2412,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3752,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3752,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,2572.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4824,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5360,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2412,16784.25,
ANGIOGRM AORTA FEM NONSEL,4121033,CDM,481,RC,36200,HCPCS,Outpatient,,,920,552,,165.6,18,,,percent of total billed charges,pays at 18% of total charges,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,644,70,,,percent of total billed charges,70% of total billed charges,690,75,,,percent of total billed charges,75% of total billed charges,460,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,736,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,703.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,552,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,644,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,920,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,828,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.16,5082.45,
STENT CORONARY,4121034,CDM,278,RC,C1876,HCPCS,Outpatient,,,6715,4029,,1208.7,18,,,percent of total billed charges,pays at 18% of total charges,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1208.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4700.5,70,,,percent of total billed charges,70% of total billed charges,5036.25,75,,,percent of total billed charges,75% of total billed charges,3357.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5372,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4029,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6715,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1156.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3021.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4700.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4029,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2551.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4700.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3223.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6715,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6715,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1052.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1052.24,6715,
RETRIEVAL OF FOREIGN BODY,4121037,CDM,481,RC,37197,HCPCS,Outpatient,,,3933.72,2360.23,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2753.6,70,,,percent of total billed charges,70% of total billed charges,2950.29,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3146.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3009.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,677.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1770.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2753.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2360.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2753.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1888.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3540.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,616.41,9586.95,
CATHETER ABLATION,4121041,CDM,272,RC,C1733,HCPCS,Outpatient,,,4344.48,2606.69,,782.01,18,,,percent of total billed charges,pays at 18% of total charges,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,782.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3041.14,70,,,percent of total billed charges,70% of total billed charges,3258.36,75,,,percent of total billed charges,75% of total billed charges,2172.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3475.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2606.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3323.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,748.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1955.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3041.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2606.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1650.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3041.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2085.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4344.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3910.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,680.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.78,4344.48,
QUAD DIAGNOSTIC,4121043,CDM,272,RC,C1730,HCPCS,Outpatient,,,824.5,494.7,,148.41,18,,,percent of total billed charges,pays at 18% of total charges,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.15,70,,,percent of total billed charges,70% of total billed charges,618.38,75,,,percent of total billed charges,75% of total billed charges,412.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,659.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,494.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,577.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,494.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,577.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,824.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,742.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.2,824.5,
EP DECAPOLAR/OCTAPOLAR,4121044,CDM,272,RC,C1730,HCPCS,Outpatient,,,2518.55,1511.13,,453.34,18,,,percent of total billed charges,pays at 18% of total charges,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,453.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1762.99,70,,,percent of total billed charges,70% of total billed charges,1888.91,75,,,percent of total billed charges,75% of total billed charges,1259.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2014.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1511.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1926.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,433.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1762.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1511.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,957.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1762.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1208.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2518.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2266.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,394.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.66,2518.55,
ICD GENERATOR DUAL,4121045,CDM,278,RC,C1721,HCPCS,Outpatient,,,19500,11700,,3510,18,,,percent of total billed charges,pays at 18% of total charges,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3510,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13650,70,,,percent of total billed charges,70% of total billed charges,14625,75,,,percent of total billed charges,75% of total billed charges,9750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11700,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3359.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8775,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13650,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11700,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7410,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13650,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9360,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3055.65,19500,
S&I ANGIOGRAM EXTREM BILATERAL,4121046,CDM,320,RC,75716,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
S&I ANGIOGRAM EXTR UNILAT,4121049,CDM,320,RC,75710,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
PEEL AWAY SHEATH,4121057,CDM,272,RC,C1892,HCPCS,Outpatient,,,133.88,80.33,,24.1,18,,,percent of total billed charges,pays at 18% of total charges,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,70,,,percent of total billed charges,70% of total billed charges,100.41,75,,,percent of total billed charges,75% of total billed charges,66.94,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,107.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,133.88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,133.88,
ICD LEAD DUAL COIL,4121058,CDM,278,RC,C1895,HCPCS,Outpatient,,,3250,1950,,585,18,,,percent of total billed charges,pays at 18% of total charges,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,585,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,70,,,percent of total billed charges,70% of total billed charges,2437.5,75,,,percent of total billed charges,75% of total billed charges,1625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,559.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.28,3250,
STENT - PERIPHERAL,4121059,CDM,278,RC,C1876,HCPCS,Outpatient,,,4082.13,2449.28,,734.78,18,,,percent of total billed charges,pays at 18% of total charges,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,734.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2857.49,70,,,percent of total billed charges,70% of total billed charges,3061.6,75,,,percent of total billed charges,75% of total billed charges,2041.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3265.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2449.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4082.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,703.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2857.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2449.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1551.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2857.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1959.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4082.13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4082.13,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,639.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,639.67,4082.13,
CATHETER EP 20 POLES HALO,4121072,CDM,272,RC,C1731,HCPCS,Outpatient,,,4556.43,2733.86,,820.16,18,,,percent of total billed charges,pays at 18% of total charges,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3189.5,70,,,percent of total billed charges,70% of total billed charges,3417.32,75,,,percent of total billed charges,75% of total billed charges,2278.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3645.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2733.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3485.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,785.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2050.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3189.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2733.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1731.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3189.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4556.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4100.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,713.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.99,4556.43,
INTRACORONARY THROMBOLYIS,4121081,CDM,481,RC,92975,HCPCS,Outpatient,,,2410,1446,,2410,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2410,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1205,50,,,percent of total billed charges,pays at 50% of total billed charges,1687,70,,,percent of total billed charges,70% of total billed charges,1807.5,75,,,percent of total billed charges,75% of total billed charges,2410,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1928,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2410,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1843.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,415.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1687,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1446,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1687,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1156.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2169,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,377.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,2410,100,,,Fee Schedule,100% of CMS OPPS Rate,377.65,2410,
REPAIR PM/ICD LEAD-DUAL,4121085,CDM,481,RC,33220,HCPCS,Outpatient,,,4441.2,2664.72,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3108.84,70,,,percent of total billed charges,70% of total billed charges,3330.9,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3552.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.24,103,,,Fee Schedule,103% of CMS OPPS Rate,3397.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,765.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1998.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3108.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2664.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3108.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2131.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3997.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,695.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,695.94,10784,
UPGRADE PERMANENT PACER,4121087,CDM,481,RC,33214,HCPCS,Outpatient,,,8059,4835.4,,33240.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8059,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19875.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5641.3,70,,,percent of total billed charges,70% of total billed charges,6044.25,75,,,percent of total billed charges,75% of total billed charges,16901.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6447.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32864.58,350,,,Fee Schedule,350% of CMS OPPS Rate,8059,103,,,Fee Schedule,103% of CMS OPPS Rate,6165.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1388.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3626.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5641.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4835.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5641.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21596.73,100,,,Fee Schedule,100% of CMS OPPS Rate,3868.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8059,100,,,Fee Schedule,100% of CMS OPPS Rate,7253.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1262.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1262.85,33240.18,
REMOVAL PACER LEAD-SINGLE,4121088,CDM,481,RC,33234,HCPCS,Outpatient,,,3777,2266.2,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2643.9,70,,,percent of total billed charges,70% of total billed charges,2832.75,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3021.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.25,103,,,Fee Schedule,103% of CMS OPPS Rate,2889.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,650.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1699.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2643.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2266.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2643.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1812.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3399.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,591.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,591.86,10784,
REMOVAL PACER LEAD-DUAL,4121089,CDM,481,RC,33235,HCPCS,Outpatient,,,8077,4846.2,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5653.9,70,,,percent of total billed charges,70% of total billed charges,6057.75,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.25,103,,,Fee Schedule,103% of CMS OPPS Rate,6178.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1391.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3634.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5653.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4846.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5653.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3876.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7269.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1265.67,10784,
REMOVAL ICD LEADS,4121094,CDM,481,RC,33244,HCPCS,Outpatient,,,3597.12,2158.27,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2517.98,70,,,percent of total billed charges,70% of total billed charges,2697.84,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2877.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.25,103,,,Fee Schedule,103% of CMS OPPS Rate,2751.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,619.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2517.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2158.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2517.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3237.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,563.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,563.67,10784,
INS NEW/REP PM W VENT LEAD,4121126,CDM,481,RC,33207,HCPCS,Outpatient,,,12000,7200,,33240.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18682.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8400,70,,,percent of total billed charges,70% of total billed charges,9000,75,,,percent of total billed charges,75% of total billed charges,16901.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32864.58,350,,,Fee Schedule,350% of CMS OPPS Rate,9577.67,103,,,Fee Schedule,103% of CMS OPPS Rate,9180,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2067.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5400,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21596.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5760,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.4,33240.18,
INS NEW/REP PM W ART LEAD,4121127,CDM,481,RC,33206,HCPCS,Outpatient,,,12000,7200,,33240.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15105.13,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8400,70,,,percent of total billed charges,70% of total billed charges,9000,75,,,percent of total billed charges,75% of total billed charges,16901.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32864.58,350,,,Fee Schedule,350% of CMS OPPS Rate,9577.67,103,,,Fee Schedule,103% of CMS OPPS Rate,9180,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2067.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5400,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21596.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5760,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,10800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1880.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.4,33240.18,
IV THROMBOLYSIS,4121129,CDM,481,RC,92977,HCPCS,Outpatient,,,932.04,559.22,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,652.43,70,,,percent of total billed charges,70% of total billed charges,699.03,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,745.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,713.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,419.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,652.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,559.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,652.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,447.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,838.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,146.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,146.05,1070.43,
STENT UNMOUNTED,4121133,CDM,278,RC,C1877,HCPCS,Outpatient,,,2546.5,1527.9,,458.37,18,,,percent of total billed charges,pays at 18% of total charges,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1782.55,70,,,percent of total billed charges,70% of total billed charges,1909.88,75,,,percent of total billed charges,75% of total billed charges,1273.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2037.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1527.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2546.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,438.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1782.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1527.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,967.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1782.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2546.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2546.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.04,2546.5,
PULMONARY ANGIO S & I,4121135,CDM,320,RC,75743,HCPCS,Outpatient,,,4058.5,2435.1,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2840.95,70,,,percent of total billed charges,70% of total billed charges,3043.88,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3246.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,3104.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,699.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1826.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2840.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2435.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,2840.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1948.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3652.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,635.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
TRANSEPTAL SHEATH,4121136,CDM,272,RC,,,Outpatient,,,291.15,174.69,,52.41,18,,,percent of total billed charges,pays at 18% of total charges,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.58,50,,,percent of total billed charges,pays at 50% of total billed charges,203.81,70,,,percent of total billed charges,70% of total billed charges,218.36,75,,,percent of total billed charges,75% of total billed charges,145.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,203.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,291.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,262.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.62,291.15,
VENOGRAM UNILAT S & I,4121139,CDM,320,RC,75820,HCPCS,Outpatient,,,1280,768,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,896,70,,,percent of total billed charges,70% of total billed charges,960,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1024,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1280,103,,,Fee Schedule,103% of CMS OPPS Rate,979.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,576,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,614.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1280,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,200.58,4788.21,
VENOGRAM BILAT S & I,4121140,CDM,320,RC,75822,HCPCS,Outpatient,,,1600,960,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,275.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,250.72,4788.21,
6T PREPOST CARDIAC CATH OBSERVATION HR,4121142,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
INS NEW/REP PM W/DUAL LEAD,4121144,CDM,481,RC,33208,HCPCS,Outpatient,,,27749,16649.4,,33240.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19477.67,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,19424.3,70,,,percent of total billed charges,70% of total billed charges,20811.75,75,,,percent of total billed charges,75% of total billed charges,16901.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32864.58,350,,,Fee Schedule,350% of CMS OPPS Rate,9577.67,103,,,Fee Schedule,103% of CMS OPPS Rate,21227.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4781.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12487.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19424.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16649.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,19424.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21596.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13319.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,24974.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,33240.18,
EP W/INDUCTION ATTEMPT,4121161,CDM,481,RC,93620,HCPCS,Outpatient,,,4183,2509.8,,21667.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4183,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10618.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2928.1,70,,,percent of total billed charges,70% of total billed charges,3137.25,75,,,percent of total billed charges,75% of total billed charges,11017.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21422.59,350,,,Fee Schedule,350% of CMS OPPS Rate,4183,103,,,Fee Schedule,103% of CMS OPPS Rate,3200,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,720.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1882.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2928.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2509.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2928.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,14077.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2007.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4183,100,,,Fee Schedule,100% of CMS OPPS Rate,3764.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,655.48,21667.42,
EP W/CS OR LA REC,4121162,CDM,481,RC,93621,HCPCS,Outpatient,,,4183,2509.8,,752.94,18,,,percent of total billed charges,pays at 18% of total charges,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,752.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2928.1,70,,,percent of total billed charges,70% of total billed charges,3137.25,75,,,percent of total billed charges,75% of total billed charges,2091.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3346.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2509.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3200,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,720.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1882.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2928.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2509.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2928.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2007.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4183,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3764.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,655.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.48,4183,
EP POST IV DRUG INF,4121163,CDM,481,RC,93623,HCPCS,Outpatient,,,1906,1143.6,,343.08,18,,,percent of total billed charges,pays at 18% of total charges,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1334.2,70,,,percent of total billed charges,70% of total billed charges,1429.5,75,,,percent of total billed charges,75% of total billed charges,953,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1524.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1143.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1458.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,328.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1334.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1334.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,914.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1906,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1715.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.67,1906,
MAP ACC P/W SLOW TACHY LV,4121167,CDM,481,RC,93609,HCPCS,Outpatient,,,3169.2,1901.52,,570.46,18,,,percent of total billed charges,pays at 18% of total charges,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,570.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2218.44,70,,,percent of total billed charges,70% of total billed charges,2376.9,75,,,percent of total billed charges,75% of total billed charges,1584.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2535.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1901.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2424.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,546.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1426.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2218.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1901.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2218.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1521.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3169.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2852.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,496.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.61,3169.2,
EV OF ICD & LEADS @ IMPLA,4121168,CDM,480,RC,93641,HCPCS,Outpatient,,,1262.52,757.51,,227.25,18,,,percent of total billed charges,pays at 18% of total charges,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.76,70,,,percent of total billed charges,70% of total billed charges,946.89,75,,,percent of total billed charges,75% of total billed charges,631.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1010.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,757.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,965.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,217.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,883.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,757.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1196,100,,,Case rate,Pays based on per visit ,883.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1262.52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1136.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,197.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.84,1262.52,
ICD EVAL LEAD ONLY AT IMPLANT,4121172,CDM,480,RC,93640,HCPCS,Outpatient,,,862.2,517.32,,155.2,18,,,percent of total billed charges,pays at 18% of total charges,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,155.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.54,70,,,percent of total billed charges,70% of total billed charges,646.65,75,,,percent of total billed charges,75% of total billed charges,431.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,689.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,659.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,148.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,603.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,517.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1196,100,,,Case rate,Pays based on per visit ,603.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,862.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,775.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.11,1196,
INSERT PM/ICD LEAD SINGLE,4121173,CDM,481,RC,33216,HCPCS,Outpatient,,,3505.05,2103.03,,26269.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3505.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12774.4,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2453.54,70,,,percent of total billed charges,70% of total billed charges,2628.79,75,,,percent of total billed charges,75% of total billed charges,13357.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2804.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,3505.05,103,,,Fee Schedule,103% of CMS OPPS Rate,2681.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,603.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1577.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2453.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2103.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2453.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1682.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3505.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3154.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,549.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,549.24,26269.53,
INSERT PM/ICD LEAD DUAL,4121174,CDM,481,RC,33217,HCPCS,Outpatient,,,3803.85,2282.31,,26269.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3803.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15028.71,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2662.7,70,,,percent of total billed charges,70% of total billed charges,2852.89,75,,,percent of total billed charges,75% of total billed charges,13357.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3043.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,3803.85,103,,,Fee Schedule,103% of CMS OPPS Rate,2909.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,655.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1711.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2662.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2282.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2662.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1825.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3803.85,100,,,Fee Schedule,100% of CMS OPPS Rate,3423.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,596.06,26269.53,
ABLATION SVT AVNRT AP AT W EP,4121176,CDM,481,RC,93653,HCPCS,Outpatient,,,30734,18440.4,,75567.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21346.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37752.54,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,21513.8,70,,,percent of total billed charges,70% of total billed charges,23050.5,75,,,percent of total billed charges,75% of total billed charges,38424.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,24587.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74713.92,350,,,Fee Schedule,350% of CMS OPPS Rate,21773.77,103,,,Fee Schedule,103% of CMS OPPS Rate,23511.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5295.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21513.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18440.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,21513.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,49097.72,100,,,Fee Schedule,100% of CMS OPPS Rate,14752.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,27660.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4816.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,75567.81,
ABLATION VT W EP 3D MAP,4121177,CDM,481,RC,93654,HCPCS,Outpatient,,,20000,12000,,75567.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20000,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,36997.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,14000,70,,,percent of total billed charges,70% of total billed charges,15000,75,,,percent of total billed charges,75% of total billed charges,38424.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,16000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74713.92,350,,,Fee Schedule,350% of CMS OPPS Rate,20000,103,,,Fee Schedule,103% of CMS OPPS Rate,15300,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3446,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,9000,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12000,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,14000,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,49097.72,100,,,Fee Schedule,100% of CMS OPPS Rate,9600,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20000,100,,,Fee Schedule,100% of CMS OPPS Rate,18000,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3134,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3134,75567.81,
PACER LEAD ATRIAL/ VENT,4121250,CDM,278,RC,C1898,HCPCS,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,780,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
PTCA LAD,4121300,CDM,481,RC,92920,HCPCS,Outpatient,,,13409,8045.4,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7879.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges,10056.75,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10727.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,10257.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2310.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6034.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8045.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6436.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12068.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2101.19,16784.25,
PTCA BALLOON,4121301,CDM,272,RC,C1725,HCPCS,Outpatient,,,2326.03,1395.62,,418.69,18,,,percent of total billed charges,pays at 18% of total charges,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1628.22,70,,,percent of total billed charges,70% of total billed charges,1744.52,75,,,percent of total billed charges,75% of total billed charges,1163.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1860.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1395.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1779.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,400.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1628.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1395.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,883.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1628.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2326.03,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2093.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.49,2326.03,
TUOY BORST,4121302,CDM,272,RC,,,Outpatient,,,86,51.6,,15.48,18,,,percent of total billed charges,pays at 18% of total charges,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43,50,,,percent of total billed charges,pays at 50% of total billed charges,60.2,70,,,percent of total billed charges,70% of total billed charges,64.5,75,,,percent of total billed charges,75% of total billed charges,43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,86,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,86,
GUIDEWIRE PTCA,4121303,CDM,272,RC,C1769,HCPCS,Outpatient,,,629.43,377.66,,113.3,18,,,percent of total billed charges,pays at 18% of total charges,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.07,75,,,percent of total billed charges,75% of total billed charges,314.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,481.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,440.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,440.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,629.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,566.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.63,629.43,
INDEFLATOR-ANGIOPLASTY,4121304,CDM,272,RC,,,Outpatient,,,524.03,314.42,,94.33,18,,,percent of total billed charges,pays at 18% of total charges,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.02,50,,,percent of total billed charges,pays at 50% of total billed charges,366.82,70,,,percent of total billed charges,70% of total billed charges,393.02,75,,,percent of total billed charges,75% of total billed charges,262.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,419.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,314.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,400.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,366.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,314.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,366.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,524.03,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,471.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.12,524.03,
INS IA PERC BALLOON,4121305,CDM,481,RC,33967,HCPCS,Outpatient,,,2082,1249.2,,2082,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2082,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1041,50,,,percent of total billed charges,pays at 50% of total billed charges,1457.4,70,,,percent of total billed charges,70% of total billed charges,1561.5,75,,,percent of total billed charges,75% of total billed charges,2082,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1665.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2082,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1592.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,358.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,936.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1457.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1249.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1457.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,999.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,1873.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,2082,100,,,Fee Schedule,100% of CMS OPPS Rate,326.25,4185,
GUIDING CATHETER,4121306,CDM,272,RC,C1887,HCPCS,Outpatient,,,430.5,258.3,,77.49,18,,,percent of total billed charges,pays at 18% of total charges,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.88,75,,,percent of total billed charges,75% of total billed charges,215.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,329.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,301.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,430.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,387.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.46,430.5,
GUIDEWIRE-WHOLEY,4121312,CDM,272,RC,C1769,HCPCS,Outpatient,,,351.48,210.89,,63.27,18,,,percent of total billed charges,pays at 18% of total charges,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.61,75,,,percent of total billed charges,75% of total billed charges,175.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,281.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,246.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,246.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,351.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,316.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.08,351.48,
EXTENSION WIRE DOC,4121313,CDM,272,RC,C1769,HCPCS,Outpatient,,,465.8,279.48,,83.84,18,,,percent of total billed charges,pays at 18% of total charges,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.35,75,,,percent of total billed charges,75% of total billed charges,232.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,372.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,356.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,326.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,279.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,326.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,465.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,419.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.99,465.8,
"CATHETER, JUDKINS",4121320,CDM,272,RC,C1887,HCPCS,Outpatient,,,283.5,170.1,,51.03,18,,,percent of total billed charges,pays at 18% of total charges,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.63,75,,,percent of total billed charges,75% of total billed charges,141.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,226.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,283.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,255.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,283.5,
CATHETER THERMODILUTION SWAN S TIP,4121340,CDM,272,RC,C1887,HCPCS,Outpatient,,,156,93.6,,28.08,18,,,percent of total billed charges,pays at 18% of total charges,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117,75,,,percent of total billed charges,75% of total billed charges,78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,156,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,140.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,156,
HEART CATH PACK,4121360,CDM,272,RC,,,Outpatient,,,85,51,,15.3,18,,,percent of total billed charges,pays at 18% of total charges,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.5,50,,,percent of total billed charges,pays at 50% of total billed charges,59.5,70,,,percent of total billed charges,70% of total billed charges,63.75,75,,,percent of total billed charges,75% of total billed charges,42.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.32,85,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",4121440,CDM,320,RC,76000,HCPCS,Outpatient,,,833.76,500.26,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,583.63,70,,,percent of total billed charges,70% of total billed charges,625.32,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,667.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,637.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,375.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,400.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,750.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,130.65,751.51,
TEMP-PACEMAKER-INSERT,4121445,CDM,481,RC,33210,HCPCS,Outpatient,,,20685,12411,,26269.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6762.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,14479.5,70,,,percent of total billed charges,70% of total billed charges,15513.75,75,,,percent of total billed charges,75% of total billed charges,13357.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,16548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,7569.18,103,,,Fee Schedule,103% of CMS OPPS Rate,15824.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3564.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,14479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9928.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,18616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3241.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,26269.53,
CARDIOVERSION,4121517,CDM,480,RC,92960,HCPCS,Outpatient,,,1452,871.2,,1892.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1045.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1016.4,70,,,percent of total billed charges,70% of total billed charges,1089,75,,,percent of total billed charges,75% of total billed charges,962.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1161.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1871.37,350,,,Fee Schedule,350% of CMS OPPS Rate,545.36,103,,,Fee Schedule,103% of CMS OPPS Rate,1110.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,653.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,1016.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.75,100,,,Fee Schedule,100% of CMS OPPS Rate,696.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,534.66,100,,,Fee Schedule,100% of CMS OPPS Rate,227.53,1892.75,
PERPHERAL INFUSION CATH,4121520,CDM,272,RC,C1751,HCPCS,Outpatient,,,556.75,334.05,,100.22,18,,,percent of total billed charges,pays at 18% of total charges,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.73,70,,,percent of total billed charges,70% of total billed charges,417.56,75,,,percent of total billed charges,75% of total billed charges,278.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,445.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,425.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,389.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,389.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,556.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,501.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.24,556.75,
PTA WIRE,4121521,CDM,272,RC,C1769,HCPCS,Outpatient,,,237.5,142.5,,42.75,18,,,percent of total billed charges,pays at 18% of total charges,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.13,75,,,percent of total billed charges,75% of total billed charges,118.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,190,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,181.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,166.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,237.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,213.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.22,237.5,
PTA BALLOON,4121522,CDM,272,RC,C1725,HCPCS,Outpatient,,,1446.7,868.02,,260.41,18,,,percent of total billed charges,pays at 18% of total charges,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.69,70,,,percent of total billed charges,70% of total billed charges,1085.03,75,,,percent of total billed charges,75% of total billed charges,723.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1157.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,868.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1106.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,249.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1012.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,868.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,549.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1012.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1446.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1302.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.7,1446.7,
INFUSION WIRE,4121524,CDM,272,RC,C1769,HCPCS,Outpatient,,,512.5,307.5,,92.25,18,,,percent of total billed charges,pays at 18% of total charges,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384.38,75,,,percent of total billed charges,75% of total billed charges,256.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,410,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,358.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,307.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,358.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,512.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,461.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.31,512.5,
PERICARDIOCENTESIS-INITIA,4121526,CDM,481,RC,33016,HCPCS,Outpatient,,,1567.08,940.25,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1567.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,783.54,50,,,percent of total billed charges,pays at 50% of total billed charges,1096.96,70,,,percent of total billed charges,70% of total billed charges,1175.31,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1253.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1198.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,705.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1096.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,940.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1096.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,752.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1410.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1567.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,705.19,4788.21,
TEMP PACING LEAD,4121534,CDM,272,RC,,,Outpatient,,,350.5,210.3,,63.09,18,,,percent of total billed charges,pays at 18% of total charges,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.25,50,,,percent of total billed charges,pays at 50% of total billed charges,245.35,70,,,percent of total billed charges,70% of total billed charges,262.88,75,,,percent of total billed charges,75% of total billed charges,175.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,280.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,210.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,268.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,350.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,315.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.92,350.5,
VENA CAVA FILTER,4121537,CDM,278,RC,C1880,HCPCS,Outpatient,,,3947.4,2368.44,,710.53,18,,,percent of total billed charges,pays at 18% of total charges,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,710.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2763.18,70,,,percent of total billed charges,70% of total billed charges,2960.55,75,,,percent of total billed charges,75% of total billed charges,1973.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3157.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2368.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3947.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,680.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1776.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2763.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2368.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1500.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2763.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1894.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3947.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3947.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,618.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.56,3947.4,
DOUBLE LUMEN DIAG CATH,4121543,CDM,272,RC,C1887,HCPCS,Outpatient,,,219.5,131.7,,39.51,18,,,percent of total billed charges,pays at 18% of total charges,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.63,75,,,percent of total billed charges,75% of total billed charges,109.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,175.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,131.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,167.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,83.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,219.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,197.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.4,219.5,
BALLOON OCCLUSION CATH.,4121561,CDM,272,RC,C2628,HCPCS,Outpatient,,,198.05,118.83,,35.65,18,,,percent of total billed charges,pays at 18% of total charges,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.64,70,,,percent of total billed charges,70% of total billed charges,148.54,75,,,percent of total billed charges,75% of total billed charges,99.03,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,158.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,198.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,178.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,198.05,
IABP INSERT KIT,4121563,CDM,272,RC,,,Outpatient,,,308.98,185.39,,55.62,18,,,percent of total billed charges,pays at 18% of total charges,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.49,50,,,percent of total billed charges,pays at 50% of total billed charges,216.29,70,,,percent of total billed charges,70% of total billed charges,231.74,75,,,percent of total billed charges,75% of total billed charges,154.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,216.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,216.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,308.98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,278.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.42,308.98,
DOPPLER NEEDLE,4121564,CDM,272,RC,,,Outpatient,,,308.98,185.39,,55.62,18,,,percent of total billed charges,pays at 18% of total charges,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.49,50,,,percent of total billed charges,pays at 50% of total billed charges,216.29,70,,,percent of total billed charges,70% of total billed charges,231.74,75,,,percent of total billed charges,75% of total billed charges,154.49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,216.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,216.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,308.98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,278.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.42,308.98,
TRANSEPTAL NEEDLE,4121577,CDM,272,RC,,,Outpatient,,,849.15,509.49,,152.85,18,,,percent of total billed charges,pays at 18% of total charges,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,424.58,50,,,percent of total billed charges,pays at 50% of total billed charges,594.41,70,,,percent of total billed charges,70% of total billed charges,636.86,75,,,percent of total billed charges,75% of total billed charges,424.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,679.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,509.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,649.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,594.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,509.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,594.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,764.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.06,849.15,
IVC FILTER INSERTION,4121579,CDM,481,RC,37191,HCPCS,Outpatient,,,4271,2562.6,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4271,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2989.7,70,,,percent of total billed charges,70% of total billed charges,3203.25,75,,,percent of total billed charges,75% of total billed charges,8410.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4271,103,,,Fee Schedule,103% of CMS OPPS Rate,3267.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,735.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2989.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2562.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2989.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2050.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4271,100,,,Fee Schedule,100% of CMS OPPS Rate,3843.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,669.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,669.27,16540.84,
PULMONARY ANGIO SELECTIVE,4121580,CDM,481,RC,36014,HCPCS,Outpatient,,,824,494.4,,148.32,18,,,percent of total billed charges,pays at 18% of total charges,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.8,70,,,percent of total billed charges,70% of total billed charges,618,75,,,percent of total billed charges,75% of total billed charges,412,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,659.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,494.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,630.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,576.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,494.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,576.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,824,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,741.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,824,
CONTTAMINATION SLEEVE,4121587,CDM,272,RC,,,Outpatient,,,23,13.8,,4.14,18,,,percent of total billed charges,pays at 18% of total charges,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.5,50,,,percent of total billed charges,pays at 50% of total billed charges,16.1,70,,,percent of total billed charges,70% of total billed charges,17.25,75,,,percent of total billed charges,75% of total billed charges,11.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.6,23,
GUIDEWIRE SPECIALTY,4121591,CDM,272,RC,C1769,HCPCS,Outpatient,,,505,303,,90.9,18,,,percent of total billed charges,pays at 18% of total charges,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,90.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.75,75,,,percent of total billed charges,75% of total billed charges,252.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,404,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,386.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,353.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,353.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,505,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,454.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.13,505,
PTA-SM. VESSEL BALLOON,4121592,CDM,272,RC,C1725,HCPCS,Outpatient,,,1402.93,841.76,,252.53,18,,,percent of total billed charges,pays at 18% of total charges,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.05,70,,,percent of total billed charges,70% of total billed charges,1052.2,75,,,percent of total billed charges,75% of total billed charges,701.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1122.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,841.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1073.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,241.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,982.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,841.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,982.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1402.93,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1262.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.84,1402.93,
TORQUE DEVICE,4121593,CDM,272,RC,,,Outpatient,,,15,9,,2.7,18,,,percent of total billed charges,pays at 18% of total charges,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.5,50,,,percent of total billed charges,pays at 50% of total billed charges,10.5,70,,,percent of total billed charges,70% of total billed charges,11.25,75,,,percent of total billed charges,75% of total billed charges,7.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.35,15,
MANIFOLD KIT 2 PORT,4121595,CDM,272,RC,,,Outpatient,,,21,12.6,,3.78,18,,,percent of total billed charges,pays at 18% of total charges,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,21,
FEM-STOP,4121606,CDM,272,RC,,,Outpatient,,,280.08,168.05,,50.41,18,,,percent of total billed charges,pays at 18% of total charges,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.04,50,,,percent of total billed charges,pays at 50% of total billed charges,196.06,70,,,percent of total billed charges,70% of total billed charges,210.06,75,,,percent of total billed charges,75% of total billed charges,140.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,224.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,252.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.89,280.08,
SNARE/RETRIVEAL DEVICE,4121610,CDM,272,RC,C1773,HCPCS,Outpatient,,,1100.5,660.3,,198.09,18,,,percent of total billed charges,pays at 18% of total charges,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.35,70,,,percent of total billed charges,70% of total billed charges,825.38,75,,,percent of total billed charges,75% of total billed charges,550.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,880.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,660.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,841.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,770.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,660.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,770.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1100.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,990.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.45,1100.5,
GLIDE-CATHETER,4121620,CDM,272,RC,C1887,HCPCS,Outpatient,,,339,203.4,,61.02,18,,,percent of total billed charges,pays at 18% of total charges,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.25,75,,,percent of total billed charges,75% of total billed charges,169.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,271.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,259.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,237.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,203.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,237.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,305.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.12,339,
VENOGRAM INJECTION,4121622,CDM,481,RC,36005,HCPCS,Outpatient,,,2100,1260,,378,18,,,percent of total billed charges,pays at 18% of total charges,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,378,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1606.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1890,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.07,2100,
CORO STENT LAD,4121623,CDM,481,RC,92928,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16286.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STENT ADD VESS LAD,4121624,CDM,481,RC,92929,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
EV OF ICD POST IMPLANT,4121626,CDM,480,RC,93642,HCPCS,Outpatient,,,1425.96,855.58,,3594.93,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1015.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1853.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,998.17,70,,,percent of total billed charges,70% of total billed charges,1069.47,75,,,percent of total billed charges,75% of total billed charges,1827.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1140.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3554.31,350,,,Fee Schedule,350% of CMS OPPS Rate,1035.82,103,,,Fee Schedule,103% of CMS OPPS Rate,1090.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,245.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,641.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,998.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,855.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,998.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,2335.67,100,,,Fee Schedule,100% of CMS OPPS Rate,684.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1283.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,223.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.52,100,,,Fee Schedule,100% of CMS OPPS Rate,223.45,3594.93,
PTCA-ADD. VESS. LAD,4121628,CDM,481,RC,92921,HCPCS,Outpatient,,,8452.08,5071.25,,1521.37,18,,,percent of total billed charges,pays at 18% of total charges,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1521.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5916.46,70,,,percent of total billed charges,70% of total billed charges,6339.06,75,,,percent of total billed charges,75% of total billed charges,4226.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6761.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6465.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1456.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3803.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8452.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7606.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.44,8452.08,
RADIAL ARTERY KIT,4121631,CDM,272,RC,,,Outpatient,,,118.5,71.1,,21.33,18,,,percent of total billed charges,pays at 18% of total charges,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.25,50,,,percent of total billed charges,pays at 50% of total billed charges,82.95,70,,,percent of total billed charges,70% of total billed charges,88.88,75,,,percent of total billed charges,75% of total billed charges,59.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,118.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,118.5,
ABLATION AV NODE,4121647,CDM,481,RC,93650,HCPCS,Outpatient,,,4580.4,2748.24,,21667.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4580.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10835.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3206.28,70,,,percent of total billed charges,70% of total billed charges,3435.3,75,,,percent of total billed charges,75% of total billed charges,11017.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3664.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21422.59,350,,,Fee Schedule,350% of CMS OPPS Rate,4580.4,103,,,Fee Schedule,103% of CMS OPPS Rate,3504.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,789.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2061.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3206.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2748.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3206.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,14077.7,100,,,Fee Schedule,100% of CMS OPPS Rate,2198.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4580.4,100,,,Fee Schedule,100% of CMS OPPS Rate,4122.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,717.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,6120.74,100,,,Fee Schedule,100% of CMS OPPS Rate,717.75,21667.42,
CPR,4121650,CDM,480,RC,92950,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,1196,
REMOVE PM GEN ONLY,4121651,CDM,481,RC,33233,HCPCS,Outpatient,,,20685,12411,,26269.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20685,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15028.71,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,14479.5,70,,,percent of total billed charges,70% of total billed charges,15513.75,75,,,percent of total billed charges,75% of total billed charges,13357.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,16548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,7569.18,103,,,Fee Schedule,103% of CMS OPPS Rate,15824.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,14479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9928.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,18616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,20685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,26269.54,
S&I ANGIOGRAM THORACIC,4121700,CDM,320,RC,75605,HCPCS,Outpatient,,,2733.93,1640.36,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2733.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1913.75,70,,,percent of total billed charges,70% of total billed charges,2050.45,75,,,percent of total billed charges,75% of total billed charges,8410.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2187.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,2733.93,103,,,Fee Schedule,103% of CMS OPPS Rate,2091.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,471.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1230.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1913.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1640.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1913.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1312.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2733.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2460.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,428.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,364,16540.84,
S&I ANGIOGRAM ABDOMINAL,4121701,CDM,320,RC,75625,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
S&I ANGIOGRAM ILIOFEMORAL,4121702,CDM,320,RC,75630,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
ANGIOJECT CATHETER XMI,4121805,CDM,272,RC,C1757,HCPCS,Outpatient,,,2177,1306.2,,391.86,18,,,percent of total billed charges,pays at 18% of total charges,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1523.9,70,,,percent of total billed charges,70% of total billed charges,1632.75,75,,,percent of total billed charges,75% of total billed charges,1088.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1741.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1306.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1665.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,375.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1523.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1306.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,827.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1523.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2177,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1959.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,341.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.14,2177,
ANGIOJET CATHETER-SOLVENT,4121806,CDM,272,RC,C1757,HCPCS,Outpatient,,,2652,1591.2,,477.36,18,,,percent of total billed charges,pays at 18% of total charges,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,477.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856.4,70,,,percent of total billed charges,70% of total billed charges,1989,75,,,percent of total billed charges,75% of total billed charges,1326,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1591.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2028.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,456.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1193.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1856.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1591.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1007.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1856.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1272.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2652,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2386.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,415.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.57,2652,
LONG SHEATH,4121810,CDM,272,RC,C1894,HCPCS,Outpatient,,,515.5,309.3,,92.79,18,,,percent of total billed charges,pays at 18% of total charges,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.85,70,,,percent of total billed charges,70% of total billed charges,386.63,75,,,percent of total billed charges,75% of total billed charges,257.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,412.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,309.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,394.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,360.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,515.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,463.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.78,515.5,
REVEAL LOOP RECORDER,4121811,CDM,278,RC,C1764,HCPCS,Outpatient,,,6298.5,3779.1,,1133.73,18,,,percent of total billed charges,pays at 18% of total charges,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1133.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4408.95,70,,,percent of total billed charges,70% of total billed charges,4723.88,75,,,percent of total billed charges,75% of total billed charges,3149.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5038.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3779.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6298.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1085.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2834.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4408.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3779.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2393.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4408.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3023.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6298.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6298.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,986.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,986.97,6298.5,
ANGIO LOWER EXTREMITY 1ST ORDER,4121814,CDM,481,RC,36245,HCPCS,Outpatient,,,1056,633.6,,190.08,18,,,percent of total billed charges,pays at 18% of total charges,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,739.2,70,,,percent of total billed charges,70% of total billed charges,792,75,,,percent of total billed charges,75% of total billed charges,528,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,633.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,807.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,633.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1056,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,950.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.48,5082.45,
INSERT REVEAL RECORDER,4121822,CDM,481,RC,33285,HCPCS,Outpatient,,,5775,3465,,26269.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5775,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5775,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15096.24,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4042.5,70,,,percent of total billed charges,70% of total billed charges,4331.25,75,,,percent of total billed charges,75% of total billed charges,13357.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,5775,103,,,Fee Schedule,103% of CMS OPPS Rate,4417.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2598.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4042.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3465,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4042.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,2772,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5775,100,,,Fee Schedule,100% of CMS OPPS Rate,5197.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5775,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2598.75,26269.53,
REMOVE REVEAL RECORDER,4121826,CDM,481,RC,33286,HCPCS,Outpatient,,,2370.24,1422.14,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2370.24,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1181.22,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1659.17,70,,,percent of total billed charges,70% of total billed charges,1777.68,75,,,percent of total billed charges,75% of total billed charges,1061.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1896.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1813.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1659.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1422.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1659.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1137.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2133.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2370.24,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,2370.24,
RELOCATE PACER POCKET,4121831,CDM,481,RC,33222,HCPCS,Outpatient,,,3701.72,2221.03,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3701.72,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3197.87,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2591.2,70,,,percent of total billed charges,70% of total billed charges,2776.29,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2961.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,2831.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2591.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2221.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2591.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1776.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3331.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3701.72,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,5554.18,
RELOCATE ICD POCKET,4121832,CDM,481,RC,33223,HCPCS,Outpatient,,,3028.68,1817.21,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3028.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3197.87,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2120.08,70,,,percent of total billed charges,70% of total billed charges,2271.51,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2422.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,2316.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1362.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2120.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1817.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2120.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1453.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2725.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3028.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,5554.18,
REMOVE ICD GEN ONLY,4121834,CDM,481,RC,33241,HCPCS,Outpatient,,,8077,4846.2,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5653.9,70,,,percent of total billed charges,70% of total billed charges,6057.75,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6461.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.25,103,,,Fee Schedule,103% of CMS OPPS Rate,6178.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1391.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3634.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5653.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4846.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5653.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3876.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7269.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1265.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1265.67,10784,
SHEATH GUIDING-PREFACE,4121847,CDM,272,RC,C1893,HCPCS,Outpatient,,,404.5,242.7,,72.81,18,,,percent of total billed charges,pays at 18% of total charges,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.15,70,,,percent of total billed charges,70% of total billed charges,303.38,75,,,percent of total billed charges,75% of total billed charges,202.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,323.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,283.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,404.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.39,404.5,
ANGIO LOWER EXREMITY 2ND ORDER,4121912,CDM,481,RC,36246,HCPCS,Outpatient,,,1264.12,758.47,,227.54,18,,,percent of total billed charges,pays at 18% of total charges,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,884.88,70,,,percent of total billed charges,70% of total billed charges,948.09,75,,,percent of total billed charges,75% of total billed charges,632.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1011.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,758.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,967.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,217.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,884.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,758.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,884.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1264.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1137.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.09,5082.45,
ANGIO EXT EA ADDL VES S&I,4121914,CDM,320,RC,75774,HCPCS,Outpatient,,,2125.8,1275.48,,382.64,18,,,percent of total billed charges,pays at 18% of total charges,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1488.06,70,,,percent of total billed charges,70% of total billed charges,1594.35,75,,,percent of total billed charges,75% of total billed charges,1062.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1700.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1275.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1626.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,366.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,956.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1488.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1275.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,1488.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2125.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1913.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.11,2125.8,
CATH PLCMT 2ND ORD RT SUBCL/LT BRACH,4121916,CDM,481,RC,36216,HCPCS,Outpatient,,,1382,829.2,,248.76,18,,,percent of total billed charges,pays at 18% of total charges,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,248.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.4,70,,,percent of total billed charges,70% of total billed charges,1036.5,75,,,percent of total billed charges,75% of total billed charges,691,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,829.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1057.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,238.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,967.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,829.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,967.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1382,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1243.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.56,1382,
CATH PLCMT 3RD ORD RT BRACH/LT LOWR ARM,4121917,CDM,481,RC,36217,HCPCS,Outpatient,,,1529.6,917.76,,275.33,18,,,percent of total billed charges,pays at 18% of total charges,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,275.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1070.72,70,,,percent of total billed charges,70% of total billed charges,1147.2,75,,,percent of total billed charges,75% of total billed charges,764.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1223.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,917.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,263.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1070.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,917.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1070.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1529.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1376.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.69,1529.6,
ADD 2ND/3RD THORACIC/BRAC,4121918,CDM,481,RC,36218,HCPCS,Outpatient,,,1033.2,619.92,,185.98,18,,,percent of total billed charges,pays at 18% of total charges,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.24,70,,,percent of total billed charges,70% of total billed charges,774.9,75,,,percent of total billed charges,75% of total billed charges,516.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,826.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,619.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,790.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,178.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,723.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,619.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,723.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1033.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,929.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.9,1033.2,
3D MAPPING ELECTRODE KIT,4122002,CDM,272,RC,C1732,HCPCS,Outpatient,,,1358.5,815.1,,244.53,18,,,percent of total billed charges,pays at 18% of total charges,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.53,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,950.95,70,,,percent of total billed charges,70% of total billed charges,1018.88,75,,,percent of total billed charges,75% of total billed charges,679.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1086.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,815.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1039.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,234.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,950.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,815.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,516.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,950.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1358.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1222.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.88,1358.5,
UNLISTED PROC.CARDIAC SUR,4122011,CDM,481,RC,93799,HCPCS,Outpatient,,,408.4,245.04,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,285.88,70,,,percent of total billed charges,70% of total billed charges,306.3,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,326.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,312.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,183.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,285.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,245.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,285.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,196.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,367.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,64,657,
PTCA - CX,4122025,CDM,481,RC,92920,HCPCS,Outpatient,,,13409,8045.4,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7879.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges,10056.75,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10727.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,10257.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2310.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6034.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8045.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6436.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12068.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2101.19,16784.25,
PTCA - RCA,4122026,CDM,481,RC,92920,HCPCS,Outpatient,,,13409,8045.4,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7879.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges,10056.75,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10727.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,10257.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2310.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6034.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8045.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6436.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12068.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2101.19,16784.25,
PTCA ADD.VESS.CX,4122027,CDM,481,RC,92921,HCPCS,Outpatient,,,8452.08,5071.25,,1521.37,18,,,percent of total billed charges,pays at 18% of total charges,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1521.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5916.46,70,,,percent of total billed charges,70% of total billed charges,6339.06,75,,,percent of total billed charges,75% of total billed charges,4226.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6761.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6465.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1456.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3803.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8452.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7606.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.44,8452.08,
PTCA ADD.VESS.RCA,4122028,CDM,481,RC,92921,HCPCS,Outpatient,,,8452.08,5071.25,,1521.37,18,,,percent of total billed charges,pays at 18% of total charges,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1521.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5916.46,70,,,percent of total billed charges,70% of total billed charges,6339.06,75,,,percent of total billed charges,75% of total billed charges,4226.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6761.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6465.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1456.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3803.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8452.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7606.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.44,8452.08,
CORO STENT CX,4122029,CDM,481,RC,92928,HCPCS,Outpatient,,,13480,8088,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16286.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9436,70,,,percent of total billed charges,70% of total billed charges,10110,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10784,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10312.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2322.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6066,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9436,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8088,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9436,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6470.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12132,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2112.32,34162.33,
CORO STENT RCA,4122030,CDM,481,RC,92928,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16286.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STENT ADD VESS CX,4122031,CDM,481,RC,92929,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO STENT ADD VESS RCA,4122032,CDM,481,RC,92929,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CUTTING BALLOON (OTHER),4122039,CDM,272,RC,C1714,HCPCS,Outpatient,,,2676.65,1605.99,,481.8,18,,,percent of total billed charges,pays at 18% of total charges,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,481.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1873.66,70,,,percent of total billed charges,70% of total billed charges,2007.49,75,,,percent of total billed charges,75% of total billed charges,1338.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2141.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2047.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,461.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1204.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1873.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1605.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1017.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1873.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2676.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2408.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,419.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.43,2676.65,
COVERED STENT,4122040,CDM,278,RC,C1874,HCPCS,Outpatient,,,5673,3403.8,,1021.14,18,,,percent of total billed charges,pays at 18% of total charges,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1021.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3971.1,70,,,percent of total billed charges,70% of total billed charges,4254.75,75,,,percent of total billed charges,75% of total billed charges,2836.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4538.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3403.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5673,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,977.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2552.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3971.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3403.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2155.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3971.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2723.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5673,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5673,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,888.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.96,5673,
CATHETER ATTAIN BALLOON,4122042,CDM,272,RC,C2628,HCPCS,Outpatient,,,675,405,,121.5,18,,,percent of total billed charges,pays at 18% of total charges,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,70,,,percent of total billed charges,70% of total billed charges,506.25,75,,,percent of total billed charges,75% of total billed charges,337.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,516.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,116.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,472.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,472.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,675,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,607.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.77,675,
CORO SINUS SHEATH/ GUIDE,4122043,CDM,272,RC,C1887,HCPCS,Outpatient,,,1525.5,915.3,,274.59,18,,,percent of total billed charges,pays at 18% of total charges,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1144.13,75,,,percent of total billed charges,75% of total billed charges,762.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1220.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,915.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1167.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,262.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1067.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,915.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,579.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1067.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,732.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1525.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1372.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.05,1525.5,
MAPPING ESI,4122044,CDM,481,RC,93613,HCPCS,Outpatient,,,754,452.4,,135.72,18,,,percent of total billed charges,pays at 18% of total charges,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.8,70,,,percent of total billed charges,70% of total billed charges,565.5,75,,,percent of total billed charges,75% of total billed charges,377,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,603.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,452.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,576.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,527.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,527.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,754,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,678.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.15,754,
VENOGRAPHY SINUS/JUGULAR,4122055,CDM,320,RC,75860,HCPCS,Outpatient,,,1400.8,840.48,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1400.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,980.56,70,,,percent of total billed charges,70% of total billed charges,1050.6,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1120.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,1400.8,103,,,Fee Schedule,103% of CMS OPPS Rate,1071.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,241.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,630.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,980.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,840.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,980.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,672.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1400.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,219.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,219.51,9586.96,
UNLISTED PROCEDURE,4122056,CDM,481,RC,33999,HCPCS,Outpatient,,,630.8,378.48,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,441.56,70,,,percent of total billed charges,70% of total billed charges,473.1,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,482.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,283.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,441.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,302.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,567.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,98.85,1861.73,
PLACEMENT CENTRAL VENOUS,4122058,CDM,481,RC,36556,HCPCS,Outpatient,,,2004,1202.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2004,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1402.8,70,,,percent of total billed charges,70% of total billed charges,1503,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1603.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2004,103,,,Fee Schedule,103% of CMS OPPS Rate,1533.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,901.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1402.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1202.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1402.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,961.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2004,100,,,Fee Schedule,100% of CMS OPPS Rate,1803.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2004,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,901.8,9586.95,
ANGIOJET (THROMBECTOMY),4122060,CDM,481,RC,92973,HCPCS,Outpatient,,,4051,2430.6,,729.18,18,,,percent of total billed charges,pays at 18% of total charges,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,729.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2835.7,70,,,percent of total billed charges,70% of total billed charges,3038.25,75,,,percent of total billed charges,75% of total billed charges,2025.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3240.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2430.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3099.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,697.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1822.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2835.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2430.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2835.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1944.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4051,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3645.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,634.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.79,4051,
ICD GEN SINGLE,4122066,CDM,278,RC,C1722,HCPCS,Outpatient,,,15600,9360,,2808,18,,,percent of total billed charges,pays at 18% of total charges,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2808,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10920,70,,,percent of total billed charges,70% of total billed charges,11700,75,,,percent of total billed charges,75% of total billed charges,7800,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9360,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2687.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7020,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9360,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5928,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10920,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7488,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2444.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2444.52,15600,
ICD LEAD SING COIL,4122067,CDM,278,RC,C1777,HCPCS,Outpatient,,,3250,1950,,585,18,,,percent of total billed charges,pays at 18% of total charges,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,585,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2275,70,,,percent of total billed charges,70% of total billed charges,2437.5,75,,,percent of total billed charges,75% of total billed charges,1625,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,559.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1950,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1235,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2275,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1560,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3250,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,509.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.28,3250,
ICD LEAD ATRIAL,4122068,CDM,278,RC,C1896,HCPCS,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,780,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
PACER GEN DUAL RATE RESPONSE,4122070,CDM,275,RC,C1785,HCPCS,Outpatient,,,3900,2340,,702,18,,,percent of total billed charges,pays at 18% of total charges,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,70,,,percent of total billed charges,70% of total billed charges,2925,75,,,percent of total billed charges,75% of total billed charges,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2983.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,671.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1755,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1482,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3510,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.13,3900,
PACE GEN SINGLE RATE RESPONSE,4122072,CDM,275,RC,C1786,HCPCS,Outpatient,,,3900,2340,,702,18,,,percent of total billed charges,pays at 18% of total charges,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2730,70,,,percent of total billed charges,70% of total billed charges,2925,75,,,percent of total billed charges,75% of total billed charges,1950,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2983.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,671.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1755,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2340,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1482,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2730,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3510,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,611.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.13,3900,
PACER GEN BI VENT,4122073,CDM,275,RC,C2621,HCPCS,Outpatient,,,7800,4680,,1404,18,,,percent of total billed charges,pays at 18% of total charges,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1404,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5460,70,,,percent of total billed charges,70% of total billed charges,5850,75,,,percent of total billed charges,75% of total billed charges,3900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5967,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1343.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3510,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2964,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7020,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.26,7800,
PACEMAKER LEAD CORO SINUS,4122074,CDM,278,RC,C1900,HCPCS,Outpatient,,,2600,1560,,468,18,,,percent of total billed charges,pays at 18% of total charges,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,70,,,percent of total billed charges,70% of total billed charges,1950,75,,,percent of total billed charges,75% of total billed charges,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,447.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,988,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.42,2600,
REPOSITION PM/ICD LEAD,4122076,CDM,481,RC,33215,HCPCS,Outpatient,,,3106.4,1863.84,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2174.48,70,,,percent of total billed charges,70% of total billed charges,2329.8,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2485.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2376.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,535.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2174.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1863.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2174.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1491.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2795.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,486.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,486.77,9586.95,
BI-V PACER/ICD EXISTING,4122077,CDM,481,RC,33224,HCPCS,Outpatient,,,27749,16649.4,,33240.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16893.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,19424.3,70,,,percent of total billed charges,70% of total billed charges,20811.75,75,,,percent of total billed charges,75% of total billed charges,16901.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,22199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32864.58,350,,,Fee Schedule,350% of CMS OPPS Rate,9577.67,103,,,Fee Schedule,103% of CMS OPPS Rate,21227.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4781.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,12487.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19424.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16649.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,19424.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21596.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13319.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,24974.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4348.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3793,33240.18,
BI-V PACER/ICD NEW GEN,4122078,CDM,481,RC,33225,HCPCS,Outpatient,,,11965,7179,,2153.7,18,,,percent of total billed charges,pays at 18% of total charges,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2153.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8375.5,70,,,percent of total billed charges,70% of total billed charges,8973.75,75,,,percent of total billed charges,75% of total billed charges,5982.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9572,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7179,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9153.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2061.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5384.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8375.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7179,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3793,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8375.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5743.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11965,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10768.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1874.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1874.92,11965,
REPOSITION BI-V LEAD,4122079,CDM,481,RC,33226,HCPCS,Outpatient,,,2103.92,1262.35,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2103.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.74,70,,,percent of total billed charges,70% of total billed charges,1577.94,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2103.92,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,362.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2103.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,329.68,9586.95,
ILIAC ANGIO W CARD CATH,4122080,CDM,481,RC,G0278,HCPCS,Outpatient,,,7025.4,4215.24,,1264.57,18,,,percent of total billed charges,pays at 18% of total charges,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1264.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4917.78,70,,,percent of total billed charges,70% of total billed charges,5269.05,75,,,percent of total billed charges,75% of total billed charges,3512.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5620.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4215.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5374.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1210.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3161.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4917.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4215.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2669.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4917.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3372.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7025.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6322.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1100.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.88,7025.4,
SUPPORT CATHETER,4122083,CDM,272,RC,,,Outpatient,,,338,202.8,,60.84,18,,,percent of total billed charges,pays at 18% of total charges,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169,50,,,percent of total billed charges,pays at 50% of total billed charges,236.6,70,,,percent of total billed charges,70% of total billed charges,253.5,75,,,percent of total billed charges,75% of total billed charges,169,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,258.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,236.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,236.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,338,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,304.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.96,338,
CORO STENT DRUG LAD,4122084,CDM,481,RC,C9600,HCPCS,Outpatient,,,14966,8979.6,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,34162.33,
CORO STENT DRUG CX,4122085,CDM,481,RC,C9600,HCPCS,Outpatient,,,14966,8979.6,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,34162.33,
CORO STENT DRUG RCA,4122086,CDM,481,RC,C9600,HCPCS,Outpatient,,,14966,8979.6,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,34162.33,
CORO STENT DRUG ADD VESS LAD,4122087,CDM,481,RC,C9601,HCPCS,Outpatient,,,14966,8979.6,,2693.88,18,,,percent of total billed charges,pays at 18% of total charges,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2693.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,7483,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14966,
CORO STENT DRUG ADD VESS CX,4122088,CDM,481,RC,C9601,HCPCS,Outpatient,,,14966,8979.6,,2693.88,18,,,percent of total billed charges,pays at 18% of total charges,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2693.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,7483,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14966,
CORO.STENT DRUG.ADD.RCA,4122089,CDM,481,RC,C9601,HCPCS,Outpatient,,,14966,8979.6,,2693.88,18,,,percent of total billed charges,pays at 18% of total charges,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2693.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,7483,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14966,
STENT CORO.DRUG ELUTING,4122090,CDM,278,RC,C1874,HCPCS,Outpatient,,,4660.55,2796.33,,838.9,18,,,percent of total billed charges,pays at 18% of total charges,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,838.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3262.39,70,,,percent of total billed charges,70% of total billed charges,3495.41,75,,,percent of total billed charges,75% of total billed charges,2330.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3728.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2796.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4660.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,803.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2097.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3262.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2796.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1771.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3262.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2237.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4660.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4660.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,730.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.31,4660.55,
ICD GEN/LEAD IMPLANT DUAL,4122094,CDM,481,RC,33249,HCPCS,Outpatient,,,87381,52428.6,,103228.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61866.12,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,61166.7,70,,,percent of total billed charges,70% of total billed charges,65535.75,75,,,percent of total billed charges,75% of total billed charges,52489.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102062.06,350,,,Fee Schedule,350% of CMS OPPS Rate,29743.79,103,,,Fee Schedule,103% of CMS OPPS Rate,66846.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15055.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,39321.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61166.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52428.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4577,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,61166.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,67069.35,100,,,Fee Schedule,100% of CMS OPPS Rate,41942.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,78642.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4577,103228.48,
ICD GEN/LEAD IMPLANT SING,4122096,CDM,481,RC,33249,HCPCS,Outpatient,,,87381,52428.6,,103228.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61866.12,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,61166.7,70,,,percent of total billed charges,70% of total billed charges,65535.75,75,,,percent of total billed charges,75% of total billed charges,52489.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69904.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102062.06,350,,,Fee Schedule,350% of CMS OPPS Rate,29743.79,103,,,Fee Schedule,103% of CMS OPPS Rate,66846.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15055.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,39321.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61166.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52428.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4577,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,61166.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,67069.35,100,,,Fee Schedule,100% of CMS OPPS Rate,41942.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,78642.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13692.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4577,103228.48,
CENTRAL VENOUS  LINE FLUORO,4122097,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
D-STAT THROMBIN INJECT,4122098,CDM,272,RC,,,Outpatient,,,200.5,120.3,,36.09,18,,,percent of total billed charges,pays at 18% of total charges,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.25,50,,,percent of total billed charges,pays at 50% of total billed charges,140.35,70,,,percent of total billed charges,70% of total billed charges,150.38,75,,,percent of total billed charges,75% of total billed charges,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,200.5,
SAFEGUARD DRSG,4122099,CDM,272,RC,,,Outpatient,,,125,75,,22.5,18,,,percent of total billed charges,pays at 18% of total charges,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.5,50,,,percent of total billed charges,pays at 50% of total billed charges,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,62.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,125,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,125,
INJECT PSEUDOANEURYSM,4122101,CDM,481,RC,36002,HCPCS,Outpatient,,,736,441.6,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,515.2,70,,,percent of total billed charges,70% of total billed charges,552,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,588.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,563.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,331.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,515.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,353.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,662.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,115.33,1861.73,
CATHETER ATHERECTOMY,4122102,CDM,272,RC,C1714,HCPCS,Outpatient,,,4933,2959.8,,887.94,18,,,percent of total billed charges,pays at 18% of total charges,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,887.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3453.1,70,,,percent of total billed charges,70% of total billed charges,3699.75,75,,,percent of total billed charges,75% of total billed charges,2466.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3946.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2959.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3773.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,849.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2219.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3453.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2959.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1874.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3453.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2367.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4933,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4439.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773,4933,
ICD GEN BI VENT,4122103,CDM,278,RC,C1882,HCPCS,Outpatient,,,23400,14040,,4212,18,,,percent of total billed charges,pays at 18% of total charges,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4212,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16380,70,,,percent of total billed charges,70% of total billed charges,17550,75,,,percent of total billed charges,75% of total billed charges,11700,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,18720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14040,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23400,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4031.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10530,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14040,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8892,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,16380,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11232,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3666.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3666.78,23400,
ABD AORTA REPAIR 1 LIMB,4122105,CDM,481,RC,34703,HCPCS,Outpatient,,,1196.64,717.98,,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,598.32,50,,,percent of total billed charges,pays at 50% of total billed charges,837.65,70,,,percent of total billed charges,70% of total billed charges,897.48,75,,,percent of total billed charges,75% of total billed charges,1196.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,957.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,915.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,206.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,538.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,717.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,574.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,187.51,1571,
ABD AORTIC GRAFT REPAIR 2 LIMB,4122106,CDM,481,RC,34705,HCPCS,Outpatient,,,1994,1196.4,,1994,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1994,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,997,50,,,percent of total billed charges,pays at 50% of total billed charges,1395.8,70,,,percent of total billed charges,70% of total billed charges,1495.5,75,,,percent of total billed charges,75% of total billed charges,1994,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1595.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1994,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1525.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,343.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,897.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1395.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1196.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1395.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,957.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1794.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,1994,100,,,Fee Schedule,100% of CMS OPPS Rate,312.46,1994,
PLACMT EXTEN PROST ABD PER VESSEL (+),4122107,CDM,481,RC,34709,HCPCS,Outpatient,,,1321,792.6,,1321,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1321,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,660.5,50,,,percent of total billed charges,pays at 50% of total billed charges,924.7,70,,,percent of total billed charges,70% of total billed charges,990.75,75,,,percent of total billed charges,75% of total billed charges,1321,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1056.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1321,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1010.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,227.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,594.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,924.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,792.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,924.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,634.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1188.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,207,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,1321,100,,,Fee Schedule,100% of CMS OPPS Rate,207,1571,
AAA STENT GRAFT BIFURCATED,4122110,CDM,278,RC,,,Outpatient,,,15784.6,9470.76,,2841.23,18,,,percent of total billed charges,pays at 18% of total charges,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2841.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7892.3,50,,,percent of total billed charges,pays at 50% of total billed charges,11049.22,70,,,percent of total billed charges,70% of total billed charges,11838.45,75,,,percent of total billed charges,75% of total billed charges,7892.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12627.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9470.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15784.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7103.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11049.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9470.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5998.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11049.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7576.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15784.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,15784.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2473.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2473.45,15784.6,
AAA STENT GRAFT CONTRALATERAL,4122111,CDM,278,RC,,,Outpatient,,,6500,3900,,1170,18,,,percent of total billed charges,pays at 18% of total charges,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1170,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3250,50,,,percent of total billed charges,pays at 50% of total billed charges,4550,70,,,percent of total billed charges,70% of total billed charges,4875,75,,,percent of total billed charges,75% of total billed charges,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2470,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1018.55,6500,
SHEATH 10F-22F,4122112,CDM,272,RC,C1894,HCPCS,Outpatient,,,415,249,,74.7,18,,,percent of total billed charges,pays at 18% of total charges,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.5,70,,,percent of total billed charges,70% of total billed charges,311.25,75,,,percent of total billed charges,75% of total billed charges,207.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,317.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,290.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,415,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,373.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.03,415,
VESSEL SIZING CATHETER,4122113,CDM,272,RC,,,Outpatient,,,340,204,,61.2,18,,,percent of total billed charges,pays at 18% of total charges,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,170,50,,,percent of total billed charges,pays at 50% of total billed charges,238,70,,,percent of total billed charges,70% of total billed charges,255,75,,,percent of total billed charges,75% of total billed charges,170,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,272,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,260.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,340,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,306,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,340,
DISTAL EMBOLIC PROTECTION,4122117,CDM,272,RC,,,Outpatient,,,2222,1333.2,,399.96,18,,,percent of total billed charges,pays at 18% of total charges,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,399.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1111,50,,,percent of total billed charges,pays at 50% of total billed charges,1555.4,70,,,percent of total billed charges,70% of total billed charges,1666.5,75,,,percent of total billed charges,75% of total billed charges,1111,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1777.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1333.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1699.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,999.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1555.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1333.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,844.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1555.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1066.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2222,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1999.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.19,2222,
THROMBECT PERI MECH INT ARTERIAL,4122118,CDM,481,RC,37184,HCPCS,Outpatient,,,26820,16092,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10367.81,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges,20115,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,20517.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4621.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12069,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,12873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24138,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,34162.33,
THROMBECT PERI MECH ADD ARTERIAL,4122119,CDM,481,RC,37185,HCPCS,Outpatient,,,3311.2,1986.72,,596.02,18,,,percent of total billed charges,pays at 18% of total charges,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2317.84,70,,,percent of total billed charges,70% of total billed charges,2483.4,75,,,percent of total billed charges,75% of total billed charges,1655.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2648.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1986.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2533.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,570.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1490.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2317.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1986.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2317.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1589.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3311.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2980.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.87,3311.2,
THROMBECT PERI SECONDARY ARTERIAL,4122120,CDM,481,RC,37186,HCPCS,Outpatient,,,2719.44,1631.66,,489.5,18,,,percent of total billed charges,pays at 18% of total charges,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1903.61,70,,,percent of total billed charges,70% of total billed charges,2039.58,75,,,percent of total billed charges,75% of total billed charges,1359.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2175.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1631.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2080.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,468.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1223.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1903.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1631.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1903.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1305.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2719.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2447.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,426.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.14,2719.44,
NON MECH THROMB CATHETER,4122124,CDM,272,RC,C1757,HCPCS,Outpatient,,,609,365.4,,109.62,18,,,percent of total billed charges,pays at 18% of total charges,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.3,70,,,percent of total billed charges,70% of total billed charges,456.75,75,,,percent of total billed charges,75% of total billed charges,304.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,487.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,365.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,465.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,426.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,365.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,426.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,609,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,548.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.43,609,
LONG PEEL AWAY SHEATH,4122125,CDM,272,RC,C1892,HCPCS,Outpatient,,,443.5,266.1,,79.83,18,,,percent of total billed charges,pays at 18% of total charges,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.45,70,,,percent of total billed charges,70% of total billed charges,332.63,75,,,percent of total billed charges,75% of total billed charges,221.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,354.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,266.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,339.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,310.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,266.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,310.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,443.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,399.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.5,443.5,
ABD AORTA GRAFT REPAIR,4122127,CDM,481,RC,34701,HCPCS,Outpatient,,,1213.32,727.99,,1213.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1213.32,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,606.66,50,,,percent of total billed charges,pays at 50% of total billed charges,849.32,70,,,percent of total billed charges,70% of total billed charges,909.99,75,,,percent of total billed charges,75% of total billed charges,1213.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,970.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1213.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,928.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,209.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,545.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,849.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,727.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,849.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,582.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,190.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.32,100,,,Fee Schedule,100% of CMS OPPS Rate,190.13,1571,
OPEN FEM ART BY GROIN,4122129,CDM,481,RC,34812,HCPCS,Outpatient,,,288,172.8,,288,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,288,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,144,50,,,percent of total billed charges,pays at 50% of total billed charges,201.6,70,,,percent of total billed charges,70% of total billed charges,216,75,,,percent of total billed charges,75% of total billed charges,288,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,288,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,220.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,288,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,138.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,288,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,288,100,,,Fee Schedule,100% of CMS OPPS Rate,45.13,1571,
AAA STENT GRAFT EXTENSION,4122130,CDM,278,RC,,,Outpatient,,,5850,3510,,1053,18,,,percent of total billed charges,pays at 18% of total charges,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1053,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2925,50,,,percent of total billed charges,pays at 50% of total billed charges,4095,70,,,percent of total billed charges,70% of total billed charges,4387.5,75,,,percent of total billed charges,75% of total billed charges,2925,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5850,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2632.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4095,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2223,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4095,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2808,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,916.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,916.7,5850,
AAA STENT GRAFT BALLOON,4122131,CDM,272,RC,C1725,HCPCS,Outpatient,,,951.6,570.96,,171.29,18,,,percent of total billed charges,pays at 18% of total charges,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.12,70,,,percent of total billed charges,70% of total billed charges,713.7,75,,,percent of total billed charges,75% of total billed charges,475.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,761.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,727.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,163.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,666.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,570.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,361.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,666.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,951.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,856.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.12,951.6,
CATHETER ANGIOJET SPIROFLEX,4122132,CDM,272,RC,C1757,HCPCS,Outpatient,,,2268.5,1361.1,,408.33,18,,,percent of total billed charges,pays at 18% of total charges,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1587.95,70,,,percent of total billed charges,70% of total billed charges,1701.38,75,,,percent of total billed charges,75% of total billed charges,1134.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1814.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1361.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1735.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,390.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1587.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1361.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,862.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1587.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1088.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2268.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2041.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,355.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.47,2268.5,
ARTERIAL OCCLUSIVE DEVICE,4122134,CDM,278,RC,C1760,HCPCS,Outpatient,,,337.5,202.5,,60.75,18,,,percent of total billed charges,pays at 18% of total charges,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.25,70,,,percent of total billed charges,70% of total billed charges,253.13,75,,,percent of total billed charges,75% of total billed charges,168.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,202.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,337.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,236.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,202.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,236.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,337.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.89,337.5,
THORAC AORT GRAFT W/SUBCL,4122135,CDM,481,RC,33880,HCPCS,Outpatient,,,3444,2066.4,,3444,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3444,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1722,50,,,percent of total billed charges,pays at 50% of total billed charges,2410.8,70,,,percent of total billed charges,70% of total billed charges,2583,75,,,percent of total billed charges,75% of total billed charges,3444,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2755.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3444,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2634.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,593.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2410.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2066.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2410.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1653.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3099.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,3444,100,,,Fee Schedule,100% of CMS OPPS Rate,539.67,3444,
THORAC AORT GRFT W/OSUBCL,4122136,CDM,481,RC,33881,HCPCS,Outpatient,,,2955.2,1773.12,,2955.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2955.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.6,50,,,percent of total billed charges,pays at 50% of total billed charges,2068.64,70,,,percent of total billed charges,70% of total billed charges,2216.4,75,,,percent of total billed charges,75% of total billed charges,2955.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2364.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2955.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2260.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,509.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2068.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1773.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2068.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1418.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2659.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.2,100,,,Fee Schedule,100% of CMS OPPS Rate,463.08,2955.2,
THORAC AORT GRF W SUBCS&I,4122137,CDM,481,RC,75956,HCPCS,Outpatient,,,692,415.2,,692,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,692,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,346,50,,,percent of total billed charges,pays at 50% of total billed charges,484.4,70,,,percent of total billed charges,70% of total billed charges,519,75,,,percent of total billed charges,75% of total billed charges,692,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,553.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,692,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,692,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,529.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,311.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,484.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,415.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,692,100,,,Fee Schedule,100% of CMS OPPS Rate,262.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,484.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,332.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,692,100,,,Fee Schedule,100% of CMS OPPS Rate,622.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,692,100,,,Fee Schedule,100% of CMS OPPS Rate,108.44,692,
THORAC AORT GRF WOSUBCS&I,4122138,CDM,481,RC,75957,HCPCS,Outpatient,,,592.8,355.68,,592.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,592.8,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,296.4,50,,,percent of total billed charges,pays at 50% of total billed charges,414.96,70,,,percent of total billed charges,70% of total billed charges,444.6,75,,,percent of total billed charges,75% of total billed charges,592.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,474.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,592.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,453.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,266.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,414.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,414.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,284.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,533.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,592.8,100,,,Fee Schedule,100% of CMS OPPS Rate,92.89,592.8,
PLCMT PROX EXT THORA GRFT,4122139,CDM,481,RC,33883,HCPCS,Outpatient,,,1946.88,1168.13,,1946.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.44,50,,,percent of total billed charges,pays at 50% of total billed charges,1362.82,70,,,percent of total billed charges,70% of total billed charges,1460.16,75,,,percent of total billed charges,75% of total billed charges,1946.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1557.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1489.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,335.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,876.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1362.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1168.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1362.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,934.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1752.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,100,,,Fee Schedule,100% of CMS OPPS Rate,305.08,1946.88,
PLCMT PROX EXT THORGRTADD,4122140,CDM,481,RC,33884,HCPCS,Outpatient,,,796.8,478.08,,796.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,796.8,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,398.4,50,,,percent of total billed charges,pays at 50% of total billed charges,557.76,70,,,percent of total billed charges,70% of total billed charges,597.6,75,,,percent of total billed charges,75% of total billed charges,796.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,637.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,796.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,609.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,358.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,557.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,478.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,557.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,382.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,717.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.8,100,,,Fee Schedule,100% of CMS OPPS Rate,124.86,1571,
PLCMT PROX EXT THOR S&I,4122141,CDM,481,RC,75958,HCPCS,Outpatient,,,391.2,234.72,,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,391.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,195.6,50,,,percent of total billed charges,pays at 50% of total billed charges,273.84,70,,,percent of total billed charges,70% of total billed charges,293.4,75,,,percent of total billed charges,75% of total billed charges,391.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,312.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,299.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,176.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,148.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,273.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,352.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,61.3,391.2,
THORACIC STENT GRAFT,4122142,CDM,278,RC,,,Outpatient,,,22100,13260,,3978,18,,,percent of total billed charges,pays at 18% of total charges,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3978,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11050,50,,,percent of total billed charges,pays at 50% of total billed charges,15470,70,,,percent of total billed charges,70% of total billed charges,16575,75,,,percent of total billed charges,75% of total billed charges,11050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22100,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8398,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10608,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3463.07,22100,
STENT PERPHRL OPEN/PERC ARTERY,4122144,CDM,481,RC,37236,HCPCS,Outpatient,,,26820,16092,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges,20115,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,20517.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4621.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12069,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,12873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24138,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
STENT PERPHRL OPEN/PERC ARTERY ADD VESS,4122145,CDM,481,RC,37237,HCPCS,Outpatient,,,10028,6016.8,,1805.04,18,,,percent of total billed charges,pays at 18% of total charges,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1805.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7019.6,70,,,percent of total billed charges,70% of total billed charges,7521,75,,,percent of total billed charges,75% of total billed charges,5014,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6016.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7671.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1727.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4512.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7019.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6016.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7019.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10028,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9025.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1571.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1571.39,10028,
ANTIBACTERIAL ENVELOPE PM/ICD SMALL,4122146,CDM,272,RC,C1781,HCPCS,Outpatient,,,1202.5,721.5,,216.45,18,,,percent of total billed charges,pays at 18% of total charges,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.75,70,,,percent of total billed charges,70% of total billed charges,901.88,75,,,percent of total billed charges,75% of total billed charges,601.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,962,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,721.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,919.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,721.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,456.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,841.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1202.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1082.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.43,1202.5,
ANTIBACTERIAL ENVELOPE PM\ICD LARGE,4122147,CDM,278,RC,C1781,HCPCS,Outpatient,,,1205.5,723.3,,216.99,18,,,percent of total billed charges,pays at 18% of total charges,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,216.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.85,70,,,percent of total billed charges,70% of total billed charges,904.13,75,,,percent of total billed charges,75% of total billed charges,602.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,964.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,723.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1205.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,207.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,843.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,723.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,458.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,843.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,578.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1205.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1205.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.9,1205.5,
FFR PRESSURE WIRE,4122150,CDM,272,RC,,,Outpatient,,,875,525,,157.5,18,,,percent of total billed charges,pays at 18% of total charges,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,437.5,50,,,percent of total billed charges,pays at 50% of total billed charges,612.5,70,,,percent of total billed charges,70% of total billed charges,656.25,75,,,percent of total billed charges,75% of total billed charges,437.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,700,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,525,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,669.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,612.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,332.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,612.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,875,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,787.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.11,875,
STYLET,4122151,CDM,272,RC,,,Outpatient,,,78.75,47.25,,14.18,18,,,percent of total billed charges,pays at 18% of total charges,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.38,50,,,percent of total billed charges,pays at 50% of total billed charges,55.13,70,,,percent of total billed charges,70% of total billed charges,59.06,75,,,percent of total billed charges,75% of total billed charges,39.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.34,78.75,
EMBOLIZATION COIL ARTRY/VEIN HEMORRHAGE,4122153,CDM,481,RC,37244,HCPCS,Outpatient,,,10245.6,6147.36,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21429.78,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7171.92,70,,,percent of total billed charges,70% of total billed charges,7684.2,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8196.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,7837.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1765.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4610.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7171.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6147.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7171.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4917.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9221.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.49,34162.33,
GUIDELINER EXTENSION CATH,4122155,CDM,272,RC,C1893,HCPCS,Outpatient,,,513.5,308.1,,92.43,18,,,percent of total billed charges,pays at 18% of total charges,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.45,70,,,percent of total billed charges,70% of total billed charges,385.13,75,,,percent of total billed charges,75% of total billed charges,256.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,410.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,308.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,359.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,359.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,513.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,462.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.47,513.5,
EMBOLIZATION COIL,4122156,CDM,272,RC,,,Outpatient,,,156,93.6,,28.08,18,,,percent of total billed charges,pays at 18% of total charges,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78,50,,,percent of total billed charges,pays at 50% of total billed charges,109.2,70,,,percent of total billed charges,70% of total billed charges,117,75,,,percent of total billed charges,75% of total billed charges,78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,93.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,156,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,140.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.45,156,
LATERAL VEIN CS CATHETER,4122157,CDM,272,RC,C1887,HCPCS,Outpatient,,,506.61,303.97,,91.19,18,,,percent of total billed charges,pays at 18% of total charges,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.96,75,,,percent of total billed charges,75% of total billed charges,253.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,303.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,455.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.39,506.61,
INTRVSC DOPPLER,4122158,CDM,481,RC,93571,HCPCS,Outpatient,,,1953,1171.8,,351.54,18,,,percent of total billed charges,pays at 18% of total charges,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1367.1,70,,,percent of total billed charges,70% of total billed charges,1464.75,75,,,percent of total billed charges,75% of total billed charges,976.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1562.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1171.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1494.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,336.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1367.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1171.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1367.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1953,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1757.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.04,1953,
INTRVSC DOPPLER ADD VESS,4122159,CDM,481,RC,93572,HCPCS,Outpatient,,,1066,639.6,,191.88,18,,,percent of total billed charges,pays at 18% of total charges,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.2,70,,,percent of total billed charges,70% of total billed charges,799.5,75,,,percent of total billed charges,75% of total billed charges,533,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,852.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,639.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,815.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,183.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,746.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,746.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1066,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,959.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,167.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.04,1066,
SHEATH 11-90 CM BRITE TIP,4122161,CDM,272,RC,C1894,HCPCS,Outpatient,,,79.59,47.75,,14.33,18,,,percent of total billed charges,pays at 18% of total charges,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.71,70,,,percent of total billed charges,70% of total billed charges,59.69,75,,,percent of total billed charges,75% of total billed charges,39.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,79.59,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,79.59,
SHEATH CSG,4122162,CDM,272,RC,C1893,HCPCS,Outpatient,,,539.5,323.7,,97.11,18,,,percent of total billed charges,pays at 18% of total charges,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.65,70,,,percent of total billed charges,70% of total billed charges,404.63,75,,,percent of total billed charges,75% of total billed charges,269.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,431.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,412.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,377.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,323.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,377.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,539.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,485.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.54,539.5,
PLACEMT EXTENS THORACIC GRAFT DELAY S&I,4122164,CDM,481,RC,75959,HCPCS,Outpatient,,,391.2,234.72,,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,391.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,195.6,50,,,percent of total billed charges,pays at 50% of total billed charges,273.84,70,,,percent of total billed charges,70% of total billed charges,293.4,75,,,percent of total billed charges,75% of total billed charges,391.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,312.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,299.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,176.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,148.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,273.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,352.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,391.2,100,,,Fee Schedule,100% of CMS OPPS Rate,61.3,391.2,
PLACEMT EXTENSION THORACIC GRAFT DELAY,4122165,CDM,481,RC,33886,HCPCS,Outpatient,,,2163.2,1297.92,,2163.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.2,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1081.6,50,,,percent of total billed charges,pays at 50% of total billed charges,1514.24,70,,,percent of total billed charges,70% of total billed charges,1622.4,75,,,percent of total billed charges,75% of total billed charges,2163.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1730.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1654.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,372.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,973.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1514.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1297.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1514.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1038.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,338.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.2,100,,,Fee Schedule,100% of CMS OPPS Rate,338.97,2163.2,
PSEUDOANEURYSM COMPRESS W US,4122166,CDM,481,RC,76936,HCPCS,Outpatient,,,279.92,167.95,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.94,70,,,percent of total billed charges,70% of total billed charges,209.94,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,223.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,214.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,125.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,195.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,106.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,195.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,134.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,251.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.86,901.29,
RIGHT HEART  CATH,4122167,CDM,481,RC,93451,HCPCS,Outpatient,,,2342,1405.2,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2342,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5392.44,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1639.4,70,,,percent of total billed charges,70% of total billed charges,1756.5,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1873.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2342,103,,,Fee Schedule,103% of CMS OPPS Rate,1791.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,403.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1053.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1639.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1405.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1639.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1124.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2342,100,,,Fee Schedule,100% of CMS OPPS Rate,2107.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,366.99,9520.95,
Insertion of catheter into left heart for diagnosis,4122168,CDM,481,RC,93452,HCPCS,Outpatient,,,2360,1416,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2360,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5736.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1652,70,,,percent of total billed charges,70% of total billed charges,1770,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1888,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2360,103,,,Fee Schedule,103% of CMS OPPS Rate,1805.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,406.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1062,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1416,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1132.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2360,100,,,Fee Schedule,100% of CMS OPPS Rate,2124,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,369.81,9520.95,
LV INJECT/RECORD W RIGHT HEART,4122169,CDM,481,RC,93453,HCPCS,Outpatient,,,3422.8,2053.68,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4876.15,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2395.96,70,,,percent of total billed charges,70% of total billed charges,2567.1,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2738.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,2618.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,589.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1540.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2395.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2053.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2395.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,3080.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,536.35,9520.95,
INJECT NATIVE CORONARIES,4122170,CDM,481,RC,93454,HCPCS,Outpatient,,,7715,4629,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4876.15,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5400.5,70,,,percent of total billed charges,70% of total billed charges,5786.25,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6172,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,5901.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1329.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,3471.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5400.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4629,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5400.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3703.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6943.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1208.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1208.94,9520.95,
INJECT NATIVE CORO& BYPASS GRAFT,4122171,CDM,481,RC,93455,HCPCS,Outpatient,,,7622.56,4573.54,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5392.44,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5335.79,70,,,percent of total billed charges,70% of total billed charges,5716.92,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6098.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,5831.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1313.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,3430.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5335.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4573.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5335.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3658.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6860.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1194.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1194.46,9520.95,
INJECT NATIVE CORO W RT HEART,4122172,CDM,481,RC,93456,HCPCS,Outpatient,,,8413,5047.8,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5621.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5889.1,70,,,percent of total billed charges,70% of total billed charges,6309.75,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6730.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,6435.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1449.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,3785.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5889.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5047.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5889.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4038.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7571.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.32,9520.95,
INJ NATIVE CORO& BYPASS GRFT W RT HRT,4122173,CDM,481,RC,93457,HCPCS,Outpatient,,,9286.2,5571.72,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5736.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,6500.34,70,,,percent of total billed charges,70% of total billed charges,6964.65,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,7428.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,7103.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1600.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4178.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6500.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5571.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,6500.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4457.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8357.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1455.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1455.15,9520.95,
INJ NATIVE CORONARIES  W LV GRAM,4122174,CDM,481,RC,93458,HCPCS,Outpatient,,,11609,6965.4,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5392.44,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8126.3,70,,,percent of total billed charges,70% of total billed charges,8706.75,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8880.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2000.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,5224.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8126.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6965.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8126.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5572.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,10448.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.13,10448.1,
INJ NATV CORO BYPASS GRT W LV GRAM,4122175,CDM,481,RC,93459,HCPCS,Outpatient,,,11609,6965.4,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4876.15,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8126.3,70,,,percent of total billed charges,70% of total billed charges,8706.75,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9287.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8880.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2000.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,5224.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8126.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6965.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8126.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5572.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,10448.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1819.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.13,10448.1,
INJ NATIVE CORO LV GRAM & RT HRT,4122176,CDM,481,RC,93460,HCPCS,Outpatient,,,11637,6982.2,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5621.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8145.9,70,,,percent of total billed charges,70% of total billed charges,8727.75,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9309.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8902.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2005.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,5236.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8145.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6982.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8145.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5585.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,10473.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1823.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1823.52,10473.3,
INJ NATV CORO BYPAS GRT LVG RT HRT,4122177,CDM,481,RC,93461,HCPCS,Outpatient,,,10917,6550.2,,9520.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2689.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4876.15,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7641.9,70,,,percent of total billed charges,70% of total billed charges,8187.75,75,,,percent of total billed charges,75% of total billed charges,4841.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8733.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9413.37,350,,,Fee Schedule,350% of CMS OPPS Rate,2743.31,103,,,Fee Schedule,103% of CMS OPPS Rate,8351.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1881,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4912.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7641.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6550.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7641.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5240.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9825.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1710.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.69,9825.3,
AORTAGRM SUPRAVALVULAR W CORO,4122178,CDM,481,RC,93567,HCPCS,Outpatient,,,1195.48,717.29,,215.19,18,,,percent of total billed charges,pays at 18% of total charges,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,836.84,70,,,percent of total billed charges,70% of total billed charges,896.61,75,,,percent of total billed charges,75% of total billed charges,597.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,956.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,717.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,914.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,836.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,717.29,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,836.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1195.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1075.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.33,1195.48,
ANGIO PULMONARY W CORO (+0,4122179,CDM,481,RC,93568,HCPCS,Outpatient,,,1086.8,652.08,,195.62,18,,,percent of total billed charges,pays at 18% of total charges,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.76,70,,,percent of total billed charges,70% of total billed charges,815.1,75,,,percent of total billed charges,75% of total billed charges,543.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,869.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,652.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,831.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,760.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,652.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,760.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1086.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,978.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.3,1086.8,
PTA-ILIAC PRIMARY UNILATERAL,4122180,CDM,481,RC,37220,HCPCS,Outpatient,,,10626,6375.6,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10626,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8812.64,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7438.2,70,,,percent of total billed charges,70% of total billed charges,7969.5,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,8128.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4781.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6375.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,5100.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,9563.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,10626,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,16784.25,
PTA ILIAC ADD VESSEL UNILATERAL,4122181,CDM,481,RC,37222,HCPCS,Outpatient,,,8088.22,4852.93,,1455.88,18,,,percent of total billed charges,pays at 18% of total charges,8088.22,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1455.88,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5661.75,70,,,percent of total billed charges,70% of total billed charges,6066.17,75,,,percent of total billed charges,75% of total billed charges,4044.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6470.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4852.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6187.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3639.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5661.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4852.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5661.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3882.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8088.22,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7279.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,8088.22,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1455.88,8088.22,
STENT ILIAC PRIMARY UNILATERAL,4122182,CDM,481,RC,37221,HCPCS,Outpatient,,,26820,16092,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26820,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges,20115,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,20517.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12069,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,12873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24138,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26820,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
STENT ILIAC ADD VESSEL UNILATERAL,4122183,CDM,481,RC,37223,HCPCS,Outpatient,,,6252.12,3751.27,,1125.38,18,,,percent of total billed charges,pays at 18% of total charges,6252.12,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1125.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4376.48,70,,,percent of total billed charges,70% of total billed charges,4689.09,75,,,percent of total billed charges,75% of total billed charges,3126.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5001.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3751.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4782.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2813.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4376.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3751.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4376.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3001.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6252.12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5626.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6252.12,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.38,6252.12,
PTA FEMORAL POPLITEAL UNILATERAL,4122184,CDM,481,RC,37224,HCPCS,Outpatient,,,13409,8045.4,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8812.64,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges,10056.75,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10727.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,10257.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2310.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6034.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8045.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6436.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12068.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2101.19,16784.25,
STENT FEMORAL POPLITEAL UNILAT,4122185,CDM,481,RC,37226,HCPCS,Outpatient,,,26820,16092,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges,20115,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,20517.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4621.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12069,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,12873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24138,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
ATHERECTOMY FEM/ POPLITEAL UNILAT,4122186,CDM,481,RC,37225,HCPCS,Outpatient,,,26820,16092,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges,20115,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,20517.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4621.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12069,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,12873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24138,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
ATHERECTOMY & STENT FEM POPL UNILAT,4122187,CDM,481,RC,37227,HCPCS,Outpatient,,,17858,10714.8,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,12500.6,70,,,percent of total billed charges,70% of total billed charges,13393.5,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14286.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,13661.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3076.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,8036.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12500.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10714.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,12500.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,8571.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,16072.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2798.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2798.35,55281.18,
PTA TIB PERO PRIMARY UNILATERAL,4122188,CDM,481,RC,37228,HCPCS,Outpatient,,,26820,16092,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges,20115,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21456,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,20517.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4621.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12069,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16092,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18774,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,12873.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,24138,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4202.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,34162.33,
PTA TIB PERONEAL ADD VES UNILA,4122189,CDM,481,RC,37232,HCPCS,Outpatient,,,4158,2494.8,,748.44,18,,,percent of total billed charges,pays at 18% of total charges,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,748.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2910.6,70,,,percent of total billed charges,70% of total billed charges,3118.5,75,,,percent of total billed charges,75% of total billed charges,2079,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2494.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3180.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,716.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2910.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2494.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2910.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4158,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3742.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.56,4158,
STENT TIB PERONEAL PRIM UNILATERAL,4122190,CDM,481,RC,37230,HCPCS,Outpatient,,,12649.95,7589.97,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12649.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8854.97,70,,,percent of total billed charges,70% of total billed charges,9487.46,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10119.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,12649.95,103,,,Fee Schedule,103% of CMS OPPS Rate,9677.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2179.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5692.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8854.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7589.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8854.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6071.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12649.95,100,,,Fee Schedule,100% of CMS OPPS Rate,11384.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1982.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1982.25,55281.18,
STENT TIB PERONEAL ADD VESS UNIL,4122191,CDM,481,RC,37234,HCPCS,Outpatient,,,6213.96,3728.38,,1118.51,18,,,percent of total billed charges,pays at 18% of total charges,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1118.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4349.77,70,,,percent of total billed charges,70% of total billed charges,4660.47,75,,,percent of total billed charges,75% of total billed charges,3106.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4971.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3728.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4753.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1070.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4349.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3728.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4349.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2982.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6213.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5592.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,973.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.73,6213.96,
ARTHERECTOMY TIB PERO PRIM UNILAT,4122192,CDM,481,RC,37229,HCPCS,Outpatient,,,43145,25887,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,30201.5,70,,,percent of total billed charges,70% of total billed charges,32358.75,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,33005.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7433.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,19415.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30201.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25887,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,30201.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,20709.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,38830.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6760.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,55281.18,
ATHER TIB PERON ADD VES UNILA,4122193,CDM,481,RC,37233,HCPCS,Outpatient,,,8827.5,5296.5,,1588.95,18,,,percent of total billed charges,pays at 18% of total charges,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1588.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6179.25,70,,,percent of total billed charges,70% of total billed charges,6620.63,75,,,percent of total billed charges,75% of total billed charges,4413.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7062,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5296.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6753.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1520.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3972.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6179.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5296.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,6179.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4237.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8827.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7944.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1383.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1383.27,8827.5,
ARTH/ STENT TIB PERON PRIM UNILAT,4122194,CDM,481,RC,37231,HCPCS,Outpatient,,,13605.84,8163.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13605.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32663.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9524.09,70,,,percent of total billed charges,70% of total billed charges,10204.38,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10884.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,13605.84,103,,,Fee Schedule,103% of CMS OPPS Rate,10408.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2344.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6122.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9524.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8163.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9524.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6530.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13605.84,100,,,Fee Schedule,100% of CMS OPPS Rate,12245.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2132.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2132.04,55281.18,
ATHER/ STENT TIB PERON ADD UNILAT,4122195,CDM,481,RC,37235,HCPCS,Outpatient,,,6827.6,4096.56,,1228.97,18,,,percent of total billed charges,pays at 18% of total charges,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1228.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4779.32,70,,,percent of total billed charges,70% of total billed charges,5120.7,75,,,percent of total billed charges,75% of total billed charges,3413.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5462.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4096.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5223.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1176.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3072.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4779.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4096.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4779.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3277.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6827.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6144.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1069.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1069.88,6827.6,
INTRO NEEDLE 2ND EXT LT,4122196,CDM,481,RC,36140,HCPCS,Outpatient,,,828.96,497.38,,149.21,18,,,percent of total billed charges,pays at 18% of total charges,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,580.27,70,,,percent of total billed charges,70% of total billed charges,621.72,75,,,percent of total billed charges,75% of total billed charges,414.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,663.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,497.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,634.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,580.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,497.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,580.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,828.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,746.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.9,5082.45,
HEMOBAND HEMOSTASIS DEVICE,4122197,CDM,272,RC,,,Outpatient,,,61.25,36.75,,11.03,18,,,percent of total billed charges,pays at 18% of total charges,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.63,50,,,percent of total billed charges,pays at 50% of total billed charges,42.88,70,,,percent of total billed charges,70% of total billed charges,45.94,75,,,percent of total billed charges,75% of total billed charges,30.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.6,61.25,
INTRO NEEDLE 2ND EXT RT UPPER,4122198,CDM,481,RC,36140,HCPCS,Outpatient,,,870,522,,156.6,18,,,percent of total billed charges,pays at 18% of total charges,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,609,70,,,percent of total billed charges,70% of total billed charges,652.5,75,,,percent of total billed charges,75% of total billed charges,435,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,696,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,522,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,665.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,609,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,522,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,609,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,870,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,783,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,136.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,5082.45,
HYBRID STYLET W GUIDEWIRE,4122199,CDM,272,RC,C1769,HCPCS,Outpatient,,,300,180,,54,18,,,percent of total billed charges,pays at 18% of total charges,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225,75,,,percent of total billed charges,75% of total billed charges,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,51.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.01,300,
ILIAC ART ANEURSYM REPAIR UNILAT,4122201,CDM,481,RC,34707,HCPCS,Outpatient,,,1309.32,785.59,,1309.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1309.32,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,654.66,50,,,percent of total billed charges,pays at 50% of total billed charges,916.52,70,,,percent of total billed charges,70% of total billed charges,981.99,75,,,percent of total billed charges,75% of total billed charges,1309.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1047.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1309.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1001.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,225.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,589.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,916.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,785.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,916.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,628.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1178.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.32,100,,,Fee Schedule,100% of CMS OPPS Rate,205.17,1571,
LEFT HEART BY TRANSSEPTAL,4122202,CDM,481,RC,93462,HCPCS,Outpatient,,,4368.51,2621.11,,786.33,18,,,percent of total billed charges,pays at 18% of total charges,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3057.96,70,,,percent of total billed charges,70% of total billed charges,3276.38,75,,,percent of total billed charges,75% of total billed charges,2184.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3494.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2621.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3341.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,752.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3057.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2621.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3057.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2096.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4368.51,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3931.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,684.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,4368.51,
REM & REPL PM GEN SINGLE,4122203,CDM,480,RC,33227,HCPCS,Outpatient,,,6500,3900,,26269.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6500,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15028.71,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4550,70,,,percent of total billed charges,70% of total billed charges,4875,75,,,percent of total billed charges,75% of total billed charges,13357.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,6500,103,,,Fee Schedule,103% of CMS OPPS Rate,4972.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1119.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2925,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6500,100,,,Fee Schedule,100% of CMS OPPS Rate,5850,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.55,26269.53,
REM & REPL PM GEN DUAL,4122204,CDM,480,RC,33228,HCPCS,Outpatient,,,7000,4200,,33240.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7000,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,19875.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4900,70,,,percent of total billed charges,70% of total billed charges,5250,75,,,percent of total billed charges,75% of total billed charges,16901.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32864.58,350,,,Fee Schedule,350% of CMS OPPS Rate,7000,103,,,Fee Schedule,103% of CMS OPPS Rate,5355,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1206.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3150,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,4900,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,21596.73,100,,,Fee Schedule,100% of CMS OPPS Rate,3360,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7000,100,,,Fee Schedule,100% of CMS OPPS Rate,6300,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1096.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,9389.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1096.9,33240.18,
REM & REPL PM GEN MULT,4122205,CDM,480,RC,33229,HCPCS,Outpatient,,,7500,4500,,60090.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16974.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7500,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35855.16,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5250,70,,,percent of total billed charges,70% of total billed charges,5625,75,,,percent of total billed charges,75% of total billed charges,30554.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59411.53,350,,,Fee Schedule,350% of CMS OPPS Rate,7500,103,,,Fee Schedule,103% of CMS OPPS Rate,5737.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3375,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,5250,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,39041.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7500,100,,,Fee Schedule,100% of CMS OPPS Rate,6750,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16974.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.25,60090.51,
REM & REPL ICD GEN SINGLE,4122206,CDM,480,RC,33262,HCPCS,Outpatient,,,61478,36886.8,,73434.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20744.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45081.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,43034.6,70,,,percent of total billed charges,70% of total billed charges,46108.5,75,,,percent of total billed charges,75% of total billed charges,37339.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72604.47,350,,,Fee Schedule,350% of CMS OPPS Rate,21159.01,103,,,Fee Schedule,103% of CMS OPPS Rate,47030.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10592.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,27665.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43034.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36886.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,43034.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,47711.5,100,,,Fee Schedule,100% of CMS OPPS Rate,29509.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,55330.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9633.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,73434.23,
REM & REPL ICD GEN DUAL,4122207,CDM,480,RC,33263,HCPCS,Outpatient,,,22000,13200,,73434.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20744.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45081.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,15400,70,,,percent of total billed charges,70% of total billed charges,16500,75,,,percent of total billed charges,75% of total billed charges,37339.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,17600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72604.47,350,,,Fee Schedule,350% of CMS OPPS Rate,21159.01,103,,,Fee Schedule,103% of CMS OPPS Rate,16830,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3790.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,9900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,15400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,47711.5,100,,,Fee Schedule,100% of CMS OPPS Rate,10560,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,19800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3447.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,20744.13,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,73434.23,
REM & REPL ICD GEN MULT,4122208,CDM,480,RC,33264,HCPCS,Outpatient,,,23100,13860,,103228.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23100,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63128.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,16170,70,,,percent of total billed charges,70% of total billed charges,17325,75,,,percent of total billed charges,75% of total billed charges,52489.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,18480,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102062.06,350,,,Fee Schedule,350% of CMS OPPS Rate,23100,103,,,Fee Schedule,103% of CMS OPPS Rate,17671.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3980.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,10395,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16170,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13860,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,16170,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,67069.35,100,,,Fee Schedule,100% of CMS OPPS Rate,11088,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23100,100,,,Fee Schedule,100% of CMS OPPS Rate,20790,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3619.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,103228.48,
ANGIO SELECT RENAL UNIL,4122209,CDM,481,RC,36251,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.41,9586.96,
ANGIO SELECT RENAL BIL,4122210,CDM,481,RC,36252,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.41,9586.96,
RETRIEVAL IVC,4122211,CDM,481,RC,37193,HCPCS,Outpatient,,,3200,1920,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,551.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,501.44,9586.95,
PROSTAR XL VASC CLOUSURE,4122212,CDM,278,RC,C1760,HCPCS,Outpatient,,,487.5,292.5,,87.75,18,,,percent of total billed charges,pays at 18% of total charges,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.25,70,,,percent of total billed charges,70% of total billed charges,365.63,75,,,percent of total billed charges,75% of total billed charges,243.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,390,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,341.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,292.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,341.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,487.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,487.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.39,487.5,
EP CABLE QUADRAPOLAR,4122213,CDM,272,RC,,,Outpatient,,,132,79.2,,23.76,18,,,percent of total billed charges,pays at 18% of total charges,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66,50,,,percent of total billed charges,pays at 50% of total billed charges,92.4,70,,,percent of total billed charges,70% of total billed charges,99,75,,,percent of total billed charges,75% of total billed charges,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,132,
PACING CABLES,4122214,CDM,272,RC,,,Outpatient,,,33,19.8,,5.94,18,,,percent of total billed charges,pays at 18% of total charges,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.5,50,,,percent of total billed charges,pays at 50% of total billed charges,23.1,70,,,percent of total billed charges,70% of total billed charges,24.75,75,,,percent of total billed charges,75% of total billed charges,16.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,23.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.17,33,
PINCH TOOL,4122215,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
RADIAL GUIDEWIRE,4122216,CDM,272,RC,,,Outpatient,,,38,22.8,,6.84,18,,,percent of total billed charges,pays at 18% of total charges,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,50,,,percent of total billed charges,pays at 50% of total billed charges,26.6,70,,,percent of total billed charges,70% of total billed charges,28.5,75,,,percent of total billed charges,75% of total billed charges,19,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,30.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,26.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,38,
WRENCH KIT,4122217,CDM,272,RC,,,Outpatient,,,78.75,47.25,,14.18,18,,,percent of total billed charges,pays at 18% of total charges,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.38,50,,,percent of total billed charges,pays at 50% of total billed charges,55.13,70,,,percent of total billed charges,70% of total billed charges,59.06,75,,,percent of total billed charges,75% of total billed charges,39.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.34,78.75,
AAA STENT GRAFT BALLOON,4122218,CDM,272,RC,C1725,HCPCS,Outpatient,,,695,417,,125.1,18,,,percent of total billed charges,pays at 18% of total charges,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.5,70,,,percent of total billed charges,70% of total billed charges,521.25,75,,,percent of total billed charges,75% of total billed charges,347.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,556,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,417,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,531.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,119.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,486.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,417,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,486.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,695,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,625.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.91,695,
SUTURE SLEEVE,4122219,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
LEAD CAP,4122220,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
EP CABLE DECAPOLAR,4122221,CDM,272,RC,,,Outpatient,,,178.5,107.1,,32.13,18,,,percent of total billed charges,pays at 18% of total charges,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.25,50,,,percent of total billed charges,pays at 50% of total billed charges,124.95,70,,,percent of total billed charges,70% of total billed charges,133.88,75,,,percent of total billed charges,75% of total billed charges,89.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,124.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,178.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,160.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.97,178.5,
EP CABLE TWENTY POLE,4122222,CDM,272,RC,,,Outpatient,,,309,185.4,,55.62,18,,,percent of total billed charges,pays at 18% of total charges,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,154.5,50,,,percent of total billed charges,pays at 50% of total billed charges,216.3,70,,,percent of total billed charges,70% of total billed charges,231.75,75,,,percent of total billed charges,75% of total billed charges,154.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,247.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,185.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,236.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,216.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,185.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,117.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,216.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,309,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,278.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.42,309,
PIN PLUG,4122223,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
CABLE EP ABLATION,4122224,CDM,272,RC,,,Outpatient,,,367,220.2,,66.06,18,,,percent of total billed charges,pays at 18% of total charges,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.5,50,,,percent of total billed charges,pays at 50% of total billed charges,256.9,70,,,percent of total billed charges,70% of total billed charges,275.25,75,,,percent of total billed charges,75% of total billed charges,183.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,293.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,220.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,139.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,256.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,367,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,330.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.51,367,
RV RA INJECTION SELECTIVE,4122225,CDM,481,RC,93566,HCPCS,Outpatient,,,2360,1416,,424.8,18,,,percent of total billed charges,pays at 18% of total charges,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652,70,,,percent of total billed charges,70% of total billed charges,1770,75,,,percent of total billed charges,75% of total billed charges,1180,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1888,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1416,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1805.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,406.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1062,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1416,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1652,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1132.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2360,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2124,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,369.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.81,2360,
PERIPHERAL SUPPORT CATHETER,4122226,CDM,272,RC,,,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.5,50,,,percent of total billed charges,pays at 50% of total billed charges,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
CATHETER CTO ATHERECTOMY,4122227,CDM,272,RC,,,Outpatient,,,2203.5,1322.1,,396.63,18,,,percent of total billed charges,pays at 18% of total charges,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,396.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1101.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1542.45,70,,,percent of total billed charges,70% of total billed charges,1652.63,75,,,percent of total billed charges,75% of total billed charges,1101.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1762.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1322.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1685.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1542.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1322.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,837.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1542.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1983.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.29,2203.5,
CORO ULTRASOUND,4122279,CDM,481,RC,92978,HCPCS,Outpatient,,,3857.92,2314.75,,694.43,18,,,percent of total billed charges,pays at 18% of total charges,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700.54,70,,,percent of total billed charges,70% of total billed charges,2893.44,75,,,percent of total billed charges,75% of total billed charges,1928.96,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3086.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2314.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2951.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,664.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1736.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2700.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2314.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2700.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1851.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3857.92,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3472.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.54,3857.92,
CORO ULTRASOUND CATHETER,4122280,CDM,272,RC,C1753,HCPCS,Outpatient,,,1365,819,,245.7,18,,,percent of total billed charges,pays at 18% of total charges,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.5,70,,,percent of total billed charges,70% of total billed charges,1023.75,75,,,percent of total billed charges,75% of total billed charges,682.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1092,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,819,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1044.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,235.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,955.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,819,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,518.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,955.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1365,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1228.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,213.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.9,1365,
PERI ARTERY THROMBOLYSIS INITIAL,4123000,CDM,481,RC,37211,HCPCS,Outpatient,,,12441,7464.6,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8708.7,70,,,percent of total billed charges,70% of total billed charges,9330.75,75,,,percent of total billed charges,75% of total billed charges,8410.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4766,103,,,Fee Schedule,103% of CMS OPPS Rate,9517.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2143.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,5598.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8708.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7464.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8708.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5971.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11196.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1949.5,16540.84,
PERI VENOUS THROMBOLYSIS INITIAL,4123001,CDM,481,RC,37212,HCPCS,Outpatient,,,7501,4500.6,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.41,9586.95,
PERI ART VEN THROMBOLYSIS SUBSQ,4123002,CDM,481,RC,37213,HCPCS,Outpatient,,,4415,2649,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3090.5,70,,,percent of total billed charges,70% of total billed charges,3311.25,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3532,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3377.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,760.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1986.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3090.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2649,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3090.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2119.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3973.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,691.83,9586.95,
PERI ART VEN THROMBOLYSIS FINAL,4123003,CDM,481,RC,37214,HCPCS,Outpatient,,,4415,2649,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3090.5,70,,,percent of total billed charges,70% of total billed charges,3311.25,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3532,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3377.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,760.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1986.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3090.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2649,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3090.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2119.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3973.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,691.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,691.83,9586.95,
CORO STENT LM,4123004,CDM,481,RC,92928,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16286.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STENT RAMUS,4123005,CDM,481,RC,92928,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16286.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STENT ADD VESS LM,4123006,CDM,481,RC,92929,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO STENT ADD VESS RAMUS,4123007,CDM,481,RC,92929,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
PTCA LM,4123008,CDM,481,RC,92920,HCPCS,Outpatient,,,8524.08,5114.45,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7879.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5966.86,70,,,percent of total billed charges,70% of total billed charges,6393.06,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6819.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6520.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1468.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,3835.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5966.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5114.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5966.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,4091.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,7671.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1335.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,1335.72,16784.25,
PTCA RAMUS,4123009,CDM,481,RC,92920,HCPCS,Outpatient,,,13409,8045.4,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7879.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges,10056.75,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10727.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,10257.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2310.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6034.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8045.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6436.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12068.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2101.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2101.19,16784.25,
CORO STNT ATHER BYPGRFT LAD,4123010,CDM,481,RC,92937,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STNT ATHER BYPGRFT CX,4123011,CDM,481,RC,92937,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STNT ATHER BYPGRFT RCA,4123012,CDM,481,RC,92937,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STNT ATHER BYPGRFT LM,4123013,CDM,481,RC,92937,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CORO STNT ATHER BYPGRFT RAMUS,4123014,CDM,481,RC,92937,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
AMI STNT ATHER NAT GRFT LAD,4123015,CDM,481,RC,92941,HCPCS,Outpatient,,,16046.88,9628.13,,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges,12035.16,75,,,percent of total billed charges,75% of total billed charges,16046.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12837.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12275.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2764.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,7221.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9628.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7702.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14442.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2514.55,20143.99,
AMI STNT ATHER NAT GRFT CX,4123016,CDM,481,RC,92941,HCPCS,Outpatient,,,16046.88,9628.13,,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges,12035.16,75,,,percent of total billed charges,75% of total billed charges,16046.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12837.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12275.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2764.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,7221.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9628.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7702.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14442.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2514.55,20143.99,
AMI STNT ATHER NAT GRFT RCA,4123017,CDM,481,RC,92941,HCPCS,Outpatient,,,16046.88,9628.13,,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges,12035.16,75,,,percent of total billed charges,75% of total billed charges,16046.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12837.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12275.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2764.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,7221.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9628.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7702.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14442.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2514.55,20143.99,
AMI STNT ATHER NAT GRFT LM,4123018,CDM,481,RC,92941,HCPCS,Outpatient,,,16046.88,9628.13,,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges,12035.16,75,,,percent of total billed charges,75% of total billed charges,16046.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12837.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12275.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2764.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,7221.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9628.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7702.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14442.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2514.55,20143.99,
AMI STNT ATHER NAT GRFT RAMUS,4123019,CDM,481,RC,92941,HCPCS,Outpatient,,,16046.88,9628.13,,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges,12035.16,75,,,percent of total billed charges,75% of total billed charges,16046.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12837.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12275.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2764.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,7221.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9628.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11232.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7702.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,14442.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2514.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,16046.88,100,,,Fee Schedule,100% of CMS OPPS Rate,2514.55,20143.99,
CTO STNT ATHER NATGRFT  LAD,4123020,CDM,481,RC,92943,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CTO STNT ATHER NATGRFT  CX,4123021,CDM,481,RC,92943,HCPCS,Outpatient,,,13479,8087.4,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9435.3,70,,,percent of total billed charges,70% of total billed charges,10109.25,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10783.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10311.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2322.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6065.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9435.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8087.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9435.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6469.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12131.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2112.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2112.16,34162.33,
CTO STNT ATHER NATGRFT  RCA,4123022,CDM,481,RC,92943,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CTO STNT ATHER NATGRFT  LM,4123023,CDM,481,RC,92943,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
CTO STNT ATHER NATGRFT  RAMUS,4123024,CDM,481,RC,92943,HCPCS,Outpatient,,,12837.5,7702.5,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,34162.33,
PTCA ADD VESS LM,4123025,CDM,481,RC,92921,HCPCS,Outpatient,,,8452.08,5071.25,,1521.37,18,,,percent of total billed charges,pays at 18% of total charges,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1521.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5916.46,70,,,percent of total billed charges,70% of total billed charges,6339.06,75,,,percent of total billed charges,75% of total billed charges,4226.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6761.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6465.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1456.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3803.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8452.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7606.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.44,8452.08,
PTCA ADD VESS RAMUS,4123026,CDM,481,RC,92921,HCPCS,Outpatient,,,8452.08,5071.25,,1521.37,18,,,percent of total billed charges,pays at 18% of total charges,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1521.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5916.46,70,,,percent of total billed charges,70% of total billed charges,6339.06,75,,,percent of total billed charges,75% of total billed charges,4226.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6761.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6465.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1456.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3803.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5071.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5916.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4057,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8452.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7606.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1324.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1324.44,8452.08,
CORO STNT ATHER BYP GRFT ADD VESS LAD,4123027,CDM,481,RC,92938,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO STNT ATHER BYP GRFT ADD VESS CX,4123028,CDM,481,RC,92938,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO STNT ATHER BYP GRFT ADD VESS RCA,4123029,CDM,481,RC,92938,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO STNT ATHER BYP GRFT ADD VESS LM,4123030,CDM,481,RC,92938,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO STNT ATHER BYP GRFT ADD VESS RAMUS,4123031,CDM,481,RC,92938,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CTO  STNT ATHER NAT GRFT ADD VESS LAD,4123032,CDM,481,RC,92944,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CTO STNT ATHER NAT GRFT ADD VESS CX,4123033,CDM,481,RC,92944,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CTO STNT ATHER NAT GRFT ADD VESS RCA,4123034,CDM,481,RC,92944,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CTO STNT ATHER NAT GRFT ADD VESS LM,4123035,CDM,481,RC,92944,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CTO  STNT ATHER BYP NAT ADD VESS RAMUS,4123036,CDM,481,RC,92944,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO ATHERECTOMY LAD,4123037,CDM,481,RC,92924,HCPCS,Outpatient,,,16116.48,9669.89,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2525.45,34162.33,
CORO ATHERECTOMY CX,4123038,CDM,481,RC,92924,HCPCS,Outpatient,,,16116.48,9669.89,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2525.45,34162.33,
CORO ATHERECTOMY RCA,4123039,CDM,481,RC,92924,HCPCS,Outpatient,,,16116.48,9669.89,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2525.45,34162.33,
CORO ATHERECTOMY LM,4123040,CDM,481,RC,92924,HCPCS,Outpatient,,,16116.48,9669.89,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2525.45,34162.33,
CORO ATHERECTOMY RAMUS,4123041,CDM,481,RC,92924,HCPCS,Outpatient,,,16116.48,9669.89,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2525.45,34162.33,
CORO ATHEREC STENT LAD,4123042,CDM,481,RC,92933,HCPCS,Outpatient,,,12837.5,7702.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12837.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32010.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,12837.5,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,55281.18,
CORO ATHEREC STENT CX,4123043,CDM,481,RC,92933,HCPCS,Outpatient,,,12837.5,7702.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12837.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32010.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,12837.5,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,55281.18,
CORO ATHEREC STENT RCA,4123044,CDM,481,RC,92933,HCPCS,Outpatient,,,12837.5,7702.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12837.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32010.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,12837.5,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,55281.18,
CORO ATHEREC STENT LM,4123045,CDM,481,RC,92933,HCPCS,Outpatient,,,12837.5,7702.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12837.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32010.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,12837.5,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,55281.18,
CORO ATHEREC STENT RAMUS,4123046,CDM,481,RC,92933,HCPCS,Outpatient,,,12837.5,7702.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12837.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32010.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,12837.5,103,,,Fee Schedule,103% of CMS OPPS Rate,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,Fee Schedule,100% of CMS OPPS Rate,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.64,55281.18,
CORO ATHEREC ADD VESS LAD,4123047,CDM,481,RC,92925,HCPCS,Outpatient,,,16116.48,9669.89,,2900.97,18,,,percent of total billed charges,pays at 18% of total charges,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2900.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,8058.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16116.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.45,16116.48,
CORO ATHEREC ADD VESS CX,4123048,CDM,481,RC,92925,HCPCS,Outpatient,,,16116.48,9669.89,,2900.97,18,,,percent of total billed charges,pays at 18% of total charges,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2900.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,8058.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16116.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.45,16116.48,
CORO ATHEREC ADD VESS RCA,4123049,CDM,481,RC,92925,HCPCS,Outpatient,,,16116.48,9669.89,,2900.97,18,,,percent of total billed charges,pays at 18% of total charges,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2900.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,8058.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16116.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.45,16116.48,
CORO ATHEREC ADD VESS LM,4123050,CDM,481,RC,92925,HCPCS,Outpatient,,,16116.48,9669.89,,2900.97,18,,,percent of total billed charges,pays at 18% of total charges,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2900.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,8058.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16116.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.45,16116.48,
CORO ATHEREC ADD VESS RAMUS,4123051,CDM,481,RC,92925,HCPCS,Outpatient,,,16116.48,9669.89,,2900.97,18,,,percent of total billed charges,pays at 18% of total charges,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2900.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11281.54,70,,,percent of total billed charges,70% of total billed charges,12087.36,75,,,percent of total billed charges,75% of total billed charges,8058.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12893.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12329.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2776.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9669.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11281.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7735.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16116.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14504.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2525.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.45,16116.48,
CORO ATHEREC STENT ADD VESS LAD,4123052,CDM,481,RC,92934,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO ATHEREC STENT ADD VESS CX,4123053,CDM,481,RC,92934,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO ATHEREC STENT ADD VESS RCA,4123054,CDM,481,RC,92934,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO ATHEREC STENT ADD VESS LM,4123055,CDM,481,RC,92934,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO ATHEREC STNT ADD VESS RAMUS,4123056,CDM,481,RC,92934,HCPCS,Outpatient,,,12837.5,7702.5,,2310.75,18,,,percent of total billed charges,pays at 18% of total charges,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2310.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8986.25,70,,,percent of total billed charges,70% of total billed charges,9628.13,75,,,percent of total billed charges,75% of total billed charges,6418.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10270,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9820.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2211.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7702.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8986.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12837.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11553.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2011.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.64,12837.5,
CORO ULTRASOUND ADD VESS,4123057,CDM,481,RC,92979,HCPCS,Outpatient,,,3857.6,2314.56,,694.37,18,,,percent of total billed charges,pays at 18% of total charges,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,694.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700.32,70,,,percent of total billed charges,70% of total billed charges,2893.2,75,,,percent of total billed charges,75% of total billed charges,1928.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3086.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2314.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2951.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,664.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1735.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2700.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2314.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2700.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1851.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3857.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3471.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.49,3857.6,
ABLATION 2ND ARRHYTHMIA,4123058,CDM,481,RC,93655,HCPCS,Outpatient,,,3424,2054.4,,616.32,18,,,percent of total billed charges,pays at 18% of total charges,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,616.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2396.8,70,,,percent of total billed charges,70% of total billed charges,2568,75,,,percent of total billed charges,75% of total billed charges,1712,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2739.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2054.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2619.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,589.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2396.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2054.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2396.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3424,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3081.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.54,3424,
CORO STENT DRUG LM,4123059,CDM,481,RC,C9600,HCPCS,Outpatient,,,14966,8979.6,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,34162.33,
CORO STENT DRUG RAMUS,4123060,CDM,481,RC,C9600,HCPCS,Outpatient,,,14253.54,8552.12,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,34162.33,
CORO STENT DRUG ADD VESS LM,4123061,CDM,481,RC,C9601,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO STENT DRUG ADD VESS RAMUS,4123062,CDM,481,RC,C9601,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG LAD,4123063,CDM,481,RC,C9602,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CORO ATHEREC STNT DRUG CX,4123064,CDM,481,RC,C9602,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CORO ATHEREC STNT DRUG RCA,4123065,CDM,481,RC,C9602,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CORO ATHEREC STNT DRUG LM,4123066,CDM,481,RC,C9602,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CORO ATHEREC STNT DRUG RAMUS,4123067,CDM,481,RC,C9602,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27764.37,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CORO ATHEREC STNT DRUG ADD VESS LAD,4123068,CDM,481,RC,C9603,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG ADD VESS CX,4123069,CDM,481,RC,C9603,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG ADD VESS RCA,4123070,CDM,481,RC,C9603,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG ADD VESS LM,4123071,CDM,481,RC,C9603,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG ADD VESS RAMUS,4123072,CDM,481,RC,C9603,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG GRFT LAD,4123073,CDM,481,RC,C9604,HCPCS,Outpatient,,,14253.54,8552.12,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,34162.33,
CORO ATHEREC STNT DRUG GRFT CX,4123074,CDM,481,RC,C9604,HCPCS,Outpatient,,,14253.54,8552.12,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,34162.33,
CORO ATHEREC STNT DRUG GRFT RCA,4123075,CDM,481,RC,C9604,HCPCS,Outpatient,,,14966,8979.6,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,34162.33,
CORO ATHEREC STNT DRUG GRFT LM,4123076,CDM,481,RC,C9604,HCPCS,Outpatient,,,14253.54,8552.12,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,34162.33,
CORO ATHEREC STNT DRUG GRFT RAMUS,4123077,CDM,481,RC,C9604,HCPCS,Outpatient,,,14253.54,8552.12,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,34162.33,
CORO ATHEREC STNT DRUG GRFT ADD VESS LAD,4123078,CDM,481,RC,C9605,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG GRFT ADD VESS CX,4123079,CDM,481,RC,C9605,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG GRFT ADD VESS RCA,4123080,CDM,481,RC,C9605,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG GRFT ADD VESS LM,4123081,CDM,481,RC,C9605,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
CORO ATHEREC STNT DRUG GRFT ADD VESS RAM,4123082,CDM,481,RC,C9605,HCPCS,Outpatient,,,14253.54,8552.12,,2565.64,18,,,percent of total billed charges,pays at 18% of total charges,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2565.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,7126.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,14253.54,
AMI STNT DRUG ATHER NAT GRFT LAD,4123083,CDM,481,RC,C9606,HCPCS,Outpatient,,,14966,8979.6,,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14966,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,14966,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,30704.14,
AMI STNT DRUG ATHER NAT GRFT CX,4123084,CDM,481,RC,C9606,HCPCS,Outpatient,,,14253.54,8552.12,,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14253.54,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,14253.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,30704.14,
AMI STNT DRUG ATHER NAT GRFT RCA,4123085,CDM,481,RC,C9606,HCPCS,Outpatient,,,14966,8979.6,,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14966,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,14966,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,30704.14,
AMI STNT DRUG ATHER NAT GRFT LM,4123086,CDM,481,RC,C9606,HCPCS,Outpatient,,,14253.54,8552.12,,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14253.54,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,14253.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,30704.14,
AMI STNT DRUG ATHER NAT GRFT RAMUS,4123087,CDM,481,RC,C9606,HCPCS,Outpatient,,,14253.54,8552.12,,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14253.54,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,14253.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,30704.14,
CTO STNT DRUG ATHER NAT GRFT LAD,4123088,CDM,481,RC,C9607,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CTO STNT DRUG ATHER NAT GRFT CX,4123089,CDM,481,RC,C9607,HCPCS,Outpatient,,,14966,8979.6,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14966,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14966,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,55281.18,
CTO STNT DRUG ATHER NAT GRFT RCA,4123090,CDM,481,RC,C9607,HCPCS,Outpatient,,,14966,8979.6,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14966,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges,11224.5,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11972.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14966,103,,,Fee Schedule,103% of CMS OPPS Rate,11448.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2578.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6734.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8979.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10476.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7183.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14966,100,,,Fee Schedule,100% of CMS OPPS Rate,13469.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2345.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.17,55281.18,
CTO STNT DRUG ATHER NAT GRFT LM,4123091,CDM,481,RC,C9607,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CTO STNT DRUG ATHER NAT GRFT RAMUS,4123092,CDM,481,RC,C9607,HCPCS,Outpatient,,,14253.54,8552.12,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14253.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30704.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges,10690.16,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11402.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,14253.54,103,,,Fee Schedule,103% of CMS OPPS Rate,10903.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2455.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,6414.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8552.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9977.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6841.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,14253.54,100,,,Fee Schedule,100% of CMS OPPS Rate,12828.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2233.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.53,55281.18,
CTO STNT DRUG ATHER NAT GRFT ADDVESS LAD,4123093,CDM,481,RC,C9608,HCPCS,Outpatient,,,11661.47,6996.88,,2099.06,18,,,percent of total billed charges,pays at 18% of total charges,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2099.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8163.03,70,,,percent of total billed charges,70% of total billed charges,8746.1,75,,,percent of total billed charges,75% of total billed charges,5830.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9329.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8921.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2009.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5247.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5597.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11661.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10495.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,11661.47,
CTO STNT DRUG ATHER NAT GRFT ADDVESS CX,4123094,CDM,481,RC,C9608,HCPCS,Outpatient,,,11661.47,6996.88,,2099.06,18,,,percent of total billed charges,pays at 18% of total charges,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2099.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8163.03,70,,,percent of total billed charges,70% of total billed charges,8746.1,75,,,percent of total billed charges,75% of total billed charges,5830.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9329.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8921.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2009.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5247.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5597.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11661.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10495.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,11661.47,
CTO STNT DRUG ATHER NAT GRFT ADDVESS RCA,4123095,CDM,481,RC,C9608,HCPCS,Outpatient,,,11661.47,6996.88,,2099.06,18,,,percent of total billed charges,pays at 18% of total charges,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2099.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8163.03,70,,,percent of total billed charges,70% of total billed charges,8746.1,75,,,percent of total billed charges,75% of total billed charges,5830.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9329.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8921.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2009.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5247.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5597.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11661.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10495.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,11661.47,
CTO STNT DRUG ATHER NAT GRFT ADDVESS LM,4123096,CDM,481,RC,C9608,HCPCS,Outpatient,,,11661.47,6996.88,,2099.06,18,,,percent of total billed charges,pays at 18% of total charges,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2099.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8163.03,70,,,percent of total billed charges,70% of total billed charges,8746.1,75,,,percent of total billed charges,75% of total billed charges,5830.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9329.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8921.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2009.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5247.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5597.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11661.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10495.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,11661.47,
CTO STNT DRUG ATHER NAT GRFT ADDVESS RAM,4123097,CDM,481,RC,C9608,HCPCS,Outpatient,,,11661.47,6996.88,,2099.06,18,,,percent of total billed charges,pays at 18% of total charges,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2099.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8163.03,70,,,percent of total billed charges,70% of total billed charges,8746.1,75,,,percent of total billed charges,75% of total billed charges,5830.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9329.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8921.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2009.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5247.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6996.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8163.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5597.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11661.47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10495.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1827.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,11661.47,
ANGIO SELECT CAROTID W CEREBRAL,4123098,CDM,481,RC,36223,HCPCS,Outpatient,,,12441,7464.6,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8708.7,70,,,percent of total billed charges,70% of total billed charges,9330.75,75,,,percent of total billed charges,75% of total billed charges,8410.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9952.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4766,103,,,Fee Schedule,103% of CMS OPPS Rate,9517.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2143.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,5598.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8708.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7464.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8708.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5971.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,11196.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1949.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1949.5,16540.84,
CATH PLCMT 1ST ORD RT INNOMINTE/LT SUBCL,4123100,CDM,481,RC,36215,HCPCS,Outpatient,,,1062.8,637.68,,191.3,18,,,percent of total billed charges,pays at 18% of total charges,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.96,70,,,percent of total billed charges,70% of total billed charges,797.1,75,,,percent of total billed charges,75% of total billed charges,531.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,850.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,813.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,183.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,743.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,637.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,743.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1062.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,956.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,166.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.54,1062.8,
SHEATH SLITTER,4123101,CDM,272,RC,,,Outpatient,,,35,21,,6.3,18,,,percent of total billed charges,pays at 18% of total charges,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.5,50,,,percent of total billed charges,pays at 50% of total billed charges,24.5,70,,,percent of total billed charges,70% of total billed charges,26.25,75,,,percent of total billed charges,75% of total billed charges,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,35,
RADIAL ASSIST ARMBOARD PAD,4123102,CDM,272,RC,,,Outpatient,,,51.62,30.97,,9.29,18,,,percent of total billed charges,pays at 18% of total charges,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.81,50,,,percent of total billed charges,pays at 50% of total billed charges,36.13,70,,,percent of total billed charges,70% of total billed charges,38.72,75,,,percent of total billed charges,75% of total billed charges,25.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.62,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.09,51.62,
PERIPHERAL ULTRASOUND CATHETER,4123103,CDM,272,RC,C1753,HCPCS,Outpatient,,,1448.2,868.92,,260.68,18,,,percent of total billed charges,pays at 18% of total charges,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,260.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1013.74,70,,,percent of total billed charges,70% of total billed charges,1086.15,75,,,percent of total billed charges,75% of total billed charges,724.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1158.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,868.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,249.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1013.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,868.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,550.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1013.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1448.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1303.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,226.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.93,1448.2,
PERI ULTRSOUND INITIAL VESSEL,4123104,CDM,481,RC,37252,HCPCS,Outpatient,,,251.3,150.78,,45.23,18,,,percent of total billed charges,pays at 18% of total charges,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.91,70,,,percent of total billed charges,70% of total billed charges,188.48,75,,,percent of total billed charges,75% of total billed charges,125.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,150.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,175.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,175.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,251.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,657,
PERI ULTRASOUND ADDITIONAL VESSEL,4123105,CDM,481,RC,37253,HCPCS,Outpatient,,,200.6,120.36,,36.11,18,,,percent of total billed charges,pays at 18% of total charges,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.42,70,,,percent of total billed charges,70% of total billed charges,150.45,75,,,percent of total billed charges,75% of total billed charges,100.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,140.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.43,657,
PLASMA KNIFE COAGULATOR,4123108,CDM,272,RC,,,Outpatient,,,455,273,,81.9,18,,,percent of total billed charges,pays at 18% of total charges,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.5,50,,,percent of total billed charges,pays at 50% of total billed charges,318.5,70,,,percent of total billed charges,70% of total billed charges,341.25,75,,,percent of total billed charges,75% of total billed charges,227.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,364,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,348.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,273,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,318.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,455,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,409.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.3,455,
GUIDEWIRE RE-ENTRY,4123110,CDM,272,RC,C1769,HCPCS,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
CATHETER REENTRY,4123111,CDM,272,RC,C1887,HCPCS,Outpatient,,,3113.5,1868.1,,560.43,18,,,percent of total billed charges,pays at 18% of total charges,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2335.13,75,,,percent of total billed charges,75% of total billed charges,1556.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2490.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1868.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2381.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,536.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1401.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2179.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1868.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1183.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2179.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1494.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3113.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2802.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,487.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.89,3113.5,
ANGIO NON SELECT THORACIC AORTA,4123112,CDM,481,RC,36221,HCPCS,Outpatient,,,2481.22,1488.73,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2481.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1736.85,70,,,percent of total billed charges,70% of total billed charges,1860.92,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1984.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2481.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1898.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,427.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1116.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1736.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1488.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1736.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1190.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2481.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,388.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,388.81,9586.96,
ANGIO SELECT CAROTID W/O CEREBRAL,4123113,CDM,481,RC,36222,HCPCS,Outpatient,,,7501,4500.6,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges,5625.75,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6000.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,5738.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1292.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3375.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4500.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5250.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3600.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6750.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1175.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.41,9586.96,
ANGIO VERTEBRAL VIA SUBCL/INNOOMINATE,4123114,CDM,481,RC,36225,HCPCS,Outpatient,,,3386.9,2032.14,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2370.83,70,,,percent of total billed charges,70% of total billed charges,2540.18,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2709.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,2590.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,583.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2370.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2032.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2370.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1625.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3048.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,530.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,530.73,9586.96,
ANGIO SELECTIVE VERTEBRAL,4123115,CDM,481,RC,36226,HCPCS,Outpatient,,,3953,2371.8,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3953,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2767.1,70,,,percent of total billed charges,70% of total billed charges,2964.75,75,,,percent of total billed charges,75% of total billed charges,8410.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,3953,103,,,Fee Schedule,103% of CMS OPPS Rate,3024.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,681.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1778.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2767.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2371.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2767.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1897.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3953,100,,,Fee Schedule,100% of CMS OPPS Rate,3557.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,619.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,619.44,16540.84,
PHARM HEMODYNAMIC STUDY,4123117,CDM,481,RC,93463,HCPCS,Outpatient,,,172,103.2,,30.96,18,,,percent of total billed charges,pays at 18% of total charges,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.4,70,,,percent of total billed charges,70% of total billed charges,129,75,,,percent of total billed charges,75% of total billed charges,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,120.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,172,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,154.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,657,
S&I ANGIOGRAM VISCERAL,4123118,CDM,320,RC,75726,HCPCS,Outpatient,,,4637.5,2782.5,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4637.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3246.25,70,,,percent of total billed charges,70% of total billed charges,3478.13,75,,,percent of total billed charges,75% of total billed charges,8410.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3710,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4637.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3547.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,799.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2086.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3246.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2782.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,3246.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2226,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4637.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4173.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,726.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,364,16540.84,
ANGIO LOWER EXT 3RD ORDER,4123119,CDM,481,RC,36247,HCPCS,Outpatient,,,2864.3,1718.58,,515.57,18,,,percent of total billed charges,pays at 18% of total charges,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2005.01,70,,,percent of total billed charges,70% of total billed charges,2148.23,75,,,percent of total billed charges,75% of total billed charges,1432.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2291.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1718.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2191.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,493.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1288.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2005.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1718.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2005.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1374.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2864.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2577.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,448.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.84,5082.45,
ANDIO ADD VESS LOWER EXT 2ND 3RD ORDER,4123120,CDM,481,RC,36248,HCPCS,Outpatient,,,307.2,184.32,,55.3,18,,,percent of total billed charges,pays at 18% of total charges,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,215.04,70,,,percent of total billed charges,70% of total billed charges,230.4,75,,,percent of total billed charges,75% of total billed charges,153.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,245.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,184.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,235.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,215.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,307.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,276.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.14,8695.83,
IVC RETRIEVAL CATHETER,4123121,CDM,272,RC,C1880,HCPCS,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
MICRO SUPPORT CATHETER,4123122,CDM,272,RC,C1887,HCPCS,Outpatient,,,643.5,386.1,,115.83,18,,,percent of total billed charges,pays at 18% of total charges,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.63,75,,,percent of total billed charges,75% of total billed charges,321.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,492.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,579.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,643.5,
SHEATH BALLOON EXPANDABLE,4123123,CDM,272,RC,C1894,HCPCS,Outpatient,,,689,413.4,,124.02,18,,,percent of total billed charges,pays at 18% of total charges,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.3,70,,,percent of total billed charges,70% of total billed charges,516.75,75,,,percent of total billed charges,75% of total billed charges,344.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,551.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,413.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,527.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,482.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,413.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,261.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,482.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,689,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,620.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.97,689,
"3D MAPPING CATHETER, ENSITE ARRAY",4123124,CDM,272,RC,C1732,HCPCS,Outpatient,,,4550,2730,,819,18,,,percent of total billed charges,pays at 18% of total charges,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3185,70,,,percent of total billed charges,70% of total billed charges,3412.5,75,,,percent of total billed charges,75% of total billed charges,2275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3480.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,783.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4095,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.99,4550,
AAA FILL POLYMER,4123125,CDM,272,RC,,,Outpatient,,,650,390,,117,18,,,percent of total billed charges,pays at 18% of total charges,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,325,50,,,percent of total billed charges,pays at 50% of total billed charges,455,70,,,percent of total billed charges,70% of total billed charges,487.5,75,,,percent of total billed charges,75% of total billed charges,325,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,497.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,390,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,247,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,455,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,650,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,585,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,650,
AUTOINJECTOR FOR POLYMER,4123126,CDM,272,RC,,,Outpatient,,,300,180,,54,18,,,percent of total billed charges,pays at 18% of total charges,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,50,,,percent of total billed charges,pays at 50% of total billed charges,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.01,300,
STENT PERPHRL OPEN/PERC VEIN,4123127,CDM,481,RC,37238,HCPCS,Outpatient,,,11480.8,6888.48,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8036.56,70,,,percent of total billed charges,70% of total billed charges,8610.6,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9184.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,8782.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1978.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5166.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8036.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6888.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8036.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5510.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10332.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1799.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1799.04,34162.33,
STENT PERPHRL OPEN/PERC VEIN ADD VESSL,4123128,CDM,481,RC,37239,HCPCS,Outpatient,,,7646.96,4588.18,,1376.45,18,,,percent of total billed charges,pays at 18% of total charges,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1376.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5352.87,70,,,percent of total billed charges,70% of total billed charges,5735.22,75,,,percent of total billed charges,75% of total billed charges,3823.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6117.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4588.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5849.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1317.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3441.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5352.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4588.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5352.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3670.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7646.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6882.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1198.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.28,7646.96,
EMBOLIZATION COIL ARTRL ANURY/PSUDO/FSTL,4123129,CDM,481,RC,37242,HCPCS,Outpatient,,,10245.6,6147.36,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21001.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7171.92,70,,,percent of total billed charges,70% of total billed charges,7684.2,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8196.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,7837.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1765.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4610.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7171.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6147.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7171.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,4917.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9221.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1605.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.49,34162.33,
LV ASSIST INSERT ARTERIAL,4123130,CDM,481,RC,33990,HCPCS,Outpatient,,,25446,15267.6,,25446,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,25446,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12723,50,,,percent of total billed charges,pays at 50% of total billed charges,17812.2,70,,,percent of total billed charges,70% of total billed charges,19084.5,75,,,percent of total billed charges,75% of total billed charges,25446,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,20356.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,25446,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,19466.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4384.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,11450.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17812.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15267.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,17812.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12214.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,22901.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3987.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,25446,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,25446,
LV ASSIST DEVICE INSERTION W/ TRANSEPTAL,4123131,CDM,481,RC,33991,HCPCS,Outpatient,,,15982.5,9589.5,,15982.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15982.5,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7991.25,50,,,percent of total billed charges,pays at 50% of total billed charges,11187.75,70,,,percent of total billed charges,70% of total billed charges,11986.88,75,,,percent of total billed charges,75% of total billed charges,15982.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12786,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15982.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,12226.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2753.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11187.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9589.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11187.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7671.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,14384.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2504.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,15982.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,15982.5,
REPOSITION LV/RV ASSIST,4123132,CDM,481,RC,33993,HCPCS,Outpatient,,,15267.63,9160.58,,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15267.63,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7633.82,50,,,percent of total billed charges,pays at 50% of total billed charges,10687.34,70,,,percent of total billed charges,70% of total billed charges,11450.72,75,,,percent of total billed charges,75% of total billed charges,15267.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12214.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,11679.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2630.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6870.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10687.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9160.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10687.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7328.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13740.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,15267.63,
LV ASSIST 2.5 CATHETER,4123133,CDM,272,RC,,,Outpatient,,,32500,19500,,5850,18,,,percent of total billed charges,pays at 18% of total charges,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5850,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16250,50,,,percent of total billed charges,pays at 50% of total billed charges,22750,70,,,percent of total billed charges,70% of total billed charges,24375,75,,,percent of total billed charges,75% of total billed charges,16250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19500,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24862.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14625,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22750,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19500,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12350,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22750,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15600,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,29250,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5092.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5092.75,32500,
GUIDEWIRE CTO,4123134,CDM,272,RC,C1769,HCPCS,Outpatient,,,520,312,,93.6,18,,,percent of total billed charges,pays at 18% of total charges,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390,75,,,percent of total billed charges,75% of total billed charges,260,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,416,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,312,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,364,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,468,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.48,520,
SHEATH STEERABLE EP,4123135,CDM,272,RC,C1766,HCPCS,Outpatient,,,1235,741,,222.3,18,,,percent of total billed charges,pays at 18% of total charges,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864.5,70,,,percent of total billed charges,70% of total billed charges,926.25,75,,,percent of total billed charges,75% of total billed charges,617.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,944.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,212.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1111.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.52,1235,
LV ASSIST CP CATHETER,4123136,CDM,272,RC,,,Outpatient,,,31500,18900,,5670,18,,,percent of total billed charges,pays at 18% of total charges,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5670,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15750,50,,,percent of total billed charges,pays at 50% of total billed charges,22050,70,,,percent of total billed charges,70% of total billed charges,23625,75,,,percent of total billed charges,75% of total billed charges,15750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,25200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24097.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14175,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22050,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11970,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,22050,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,28350,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4936.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4936.05,31500,
EMBOLIZATION VASCULAR PLUG,4123137,CDM,272,RC,,,Outpatient,,,1235,741,,222.3,18,,,percent of total billed charges,pays at 18% of total charges,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.5,50,,,percent of total billed charges,pays at 50% of total billed charges,864.5,70,,,percent of total billed charges,70% of total billed charges,926.25,75,,,percent of total billed charges,75% of total billed charges,617.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,944.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1111.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.52,1235,
MICROCATHETER CTO,4123138,CDM,272,RC,C1887,HCPCS,Outpatient,,,1235,741,,222.3,18,,,percent of total billed charges,pays at 18% of total charges,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,222.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.25,75,,,percent of total billed charges,75% of total billed charges,617.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,988,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,944.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,212.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,741,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,469.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,864.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1235,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1111.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,193.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.52,1235,
EMBOLIZATION VASCULAR PLUG,4123139,CDM,272,RC,,,Outpatient,,,795.6,477.36,,143.21,18,,,percent of total billed charges,pays at 18% of total charges,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,143.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,397.8,50,,,percent of total billed charges,pays at 50% of total billed charges,556.92,70,,,percent of total billed charges,70% of total billed charges,596.7,75,,,percent of total billed charges,75% of total billed charges,397.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,636.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,477.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,608.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,556.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,477.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,302.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,556.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,795.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,716.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.67,795.6,
CATHETER CTO CROSSBOSS,4123140,CDM,272,RC,C1725,HCPCS,Outpatient,,,1885,1131,,339.3,18,,,percent of total billed charges,pays at 18% of total charges,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1319.5,70,,,percent of total billed charges,70% of total billed charges,1413.75,75,,,percent of total billed charges,75% of total billed charges,942.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1508,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1131,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1442.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,324.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1319.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1131,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,716.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1319.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,904.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1885,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1696.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,295.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.38,1885,
CATHETER CTO STINGRAY,4123141,CDM,272,RC,C1725,HCPCS,Outpatient,,,2473.5,1484.1,,445.23,18,,,percent of total billed charges,pays at 18% of total charges,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,445.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1731.45,70,,,percent of total billed charges,70% of total billed charges,1855.13,75,,,percent of total billed charges,75% of total billed charges,1236.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1978.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1484.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1892.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,426.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1731.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1484.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,939.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1731.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1187.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2473.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2226.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,387.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.6,2473.5,
LUBRICANT ROTOGLIDE,4123142,CDM,272,RC,,,Outpatient,,,132,79.2,,23.76,18,,,percent of total billed charges,pays at 18% of total charges,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66,50,,,percent of total billed charges,pays at 50% of total billed charges,92.4,70,,,percent of total billed charges,70% of total billed charges,99,75,,,percent of total billed charges,75% of total billed charges,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,132,
AAA SECUREMENT SHEATH ABDOMINAL,4123143,CDM,272,RC,,,Outpatient,,,2289.3,1373.58,,412.07,18,,,percent of total billed charges,pays at 18% of total charges,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1144.65,50,,,percent of total billed charges,pays at 50% of total billed charges,1602.51,70,,,percent of total billed charges,70% of total billed charges,1716.98,75,,,percent of total billed charges,75% of total billed charges,1144.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1831.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1373.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1751.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1602.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1373.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,869.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1602.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2289.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2060.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,358.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.73,2289.3,
AAA SECUREMENT SHEATH THORACIC,4123144,CDM,272,RC,,,Outpatient,,,2987.4,1792.44,,537.73,18,,,percent of total billed charges,pays at 18% of total charges,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1493.7,50,,,percent of total billed charges,pays at 50% of total billed charges,2091.18,70,,,percent of total billed charges,70% of total billed charges,2240.55,75,,,percent of total billed charges,75% of total billed charges,1493.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2389.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1792.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2285.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2091.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1792.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1135.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2091.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1433.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2987.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2688.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.13,2987.4,
AAA SECUREMENT APPLIER ABDOMINAL,4123145,CDM,272,RC,,,Outpatient,,,6175,3705,,1111.5,18,,,percent of total billed charges,pays at 18% of total charges,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1111.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3087.5,50,,,percent of total billed charges,pays at 50% of total billed charges,4322.5,70,,,percent of total billed charges,70% of total billed charges,4631.25,75,,,percent of total billed charges,75% of total billed charges,3087.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4940,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3705,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4723.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2778.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4322.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3705,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2346.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4322.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2964,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6175,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5557.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,967.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.62,6175,
AAA SECUREMENT APPLIER THORACIC,4123146,CDM,272,RC,,,Outpatient,,,8080.8,4848.48,,1454.54,18,,,percent of total billed charges,pays at 18% of total charges,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1454.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4040.4,50,,,percent of total billed charges,pays at 50% of total billed charges,5656.56,70,,,percent of total billed charges,70% of total billed charges,6060.6,75,,,percent of total billed charges,75% of total billed charges,4040.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6464.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4848.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6181.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3636.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5656.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4848.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3070.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5656.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3878.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8080.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7272.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1266.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1266.26,8080.8,
EMBOLIZATION COILING TUMR/ISCHMIA/INFRCT,4123147,CDM,481,RC,37243,HCPCS,Outpatient,,,12807,7684.2,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8964.9,70,,,percent of total billed charges,70% of total billed charges,9605.25,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,9797.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2206.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5763.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8964.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7684.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8964.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6147.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11526.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2006.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.86,34162.33,
VALVULOPLASTY BALLOON,4123148,CDM,272,RC,,,Outpatient,,,912.53,547.52,,164.26,18,,,percent of total billed charges,pays at 18% of total charges,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,456.27,50,,,percent of total billed charges,pays at 50% of total billed charges,638.77,70,,,percent of total billed charges,70% of total billed charges,684.4,75,,,percent of total billed charges,75% of total billed charges,456.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,730.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,547.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,698.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,638.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,547.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,346.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,638.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,912.53,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,821.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.99,912.53,
VALVULOPLASTY PERCUTANEOUS AORTIC,4123149,CDM,481,RC,92986,HCPCS,Outpatient,,,9558,5734.8,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8812.64,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,6690.6,70,,,percent of total billed charges,70% of total billed charges,7168.5,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,7646.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,7311.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1646.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4301.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6690.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5734.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,6690.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,4587.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,8602.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1497.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,1497.74,16784.25,
STATLOCK IAB STABILIZATION,4123150,CDM,272,RC,,,Outpatient,,,35.2,21.12,,6.34,18,,,percent of total billed charges,pays at 18% of total charges,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.6,50,,,percent of total billed charges,pays at 50% of total billed charges,24.64,70,,,percent of total billed charges,70% of total billed charges,26.4,75,,,percent of total billed charges,75% of total billed charges,17.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.52,35.2,
PACING CABLE DISP FOR TEMP PACER,4123151,CDM,272,RC,,,Outpatient,,,112.5,67.5,,20.25,18,,,percent of total billed charges,pays at 18% of total charges,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.25,50,,,percent of total billed charges,pays at 50% of total billed charges,78.75,70,,,percent of total billed charges,70% of total billed charges,84.38,75,,,percent of total billed charges,75% of total billed charges,56.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,90,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,112.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,101.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.63,112.5,
PACERMAKER LEAD ATRIAL/ VENT,4123152,CDM,278,RC,C1898,HCPCS,Outpatient,,,1170,702,,210.6,18,,,percent of total billed charges,pays at 18% of total charges,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819,70,,,percent of total billed charges,70% of total billed charges,877.5,75,,,percent of total billed charges,75% of total billed charges,585,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,936,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,201.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,819,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,702,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,444.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,819,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.34,1170,
PACEMAKER LEAD CORO SINUS,4123153,CDM,278,RC,C1900,HCPCS,Outpatient,,,4160,2496,,748.8,18,,,percent of total billed charges,pays at 18% of total charges,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,748.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2912,70,,,percent of total billed charges,70% of total billed charges,3120,75,,,percent of total billed charges,75% of total billed charges,2080,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2496,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4160,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,716.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2912,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2496,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1580.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2912,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1996.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.87,4160,
ICD LEAD IMPLANT,4123154,CDM,278,RC,C1896,HCPCS,Outpatient,,,1170,702,,210.6,18,,,percent of total billed charges,pays at 18% of total charges,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819,70,,,percent of total billed charges,70% of total billed charges,877.5,75,,,percent of total billed charges,75% of total billed charges,585,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,936,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,702,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,201.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,819,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,702,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,444.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,819,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,183.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.34,1170,
ICD LEAD CORO SINUS,4123155,CDM,278,RC,C1900,HCPCS,Outpatient,,,2600,1560,,468,18,,,percent of total billed charges,pays at 18% of total charges,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820,70,,,percent of total billed charges,70% of total billed charges,1950,75,,,percent of total billed charges,75% of total billed charges,1300,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2080,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2600,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,447.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1560,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,988,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1820,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2600,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,407.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.42,2600,
ICD LEAD CORO SINUS,4123156,CDM,278,RC,C1900,HCPCS,Outpatient,,,4160,2496,,748.8,18,,,percent of total billed charges,pays at 18% of total charges,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,748.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2912,70,,,percent of total billed charges,70% of total billed charges,3120,75,,,percent of total billed charges,75% of total billed charges,2080,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2496,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4160,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,716.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1872,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2912,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2496,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1580.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2912,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1996.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.87,4160,
ICD LEAD SING COIL,4123157,CDM,278,RC,C1777,HCPCS,Outpatient,,,4550,2730,,819,18,,,percent of total billed charges,pays at 18% of total charges,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3185,70,,,percent of total billed charges,70% of total billed charges,3412.5,75,,,percent of total billed charges,75% of total billed charges,2275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4550,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,783.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.99,4550,
ICD LEAD DUAL COIL,4123158,CDM,278,RC,C1895,HCPCS,Outpatient,,,4550,2730,,819,18,,,percent of total billed charges,pays at 18% of total charges,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,819,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3185,70,,,percent of total billed charges,70% of total billed charges,3412.5,75,,,percent of total billed charges,75% of total billed charges,2275,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4550,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,783.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2047.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2730,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1729,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3185,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4550,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,712.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.99,4550,
PACE GEN SINGLE RATE RESPONSE,4123159,CDM,275,RC,C1786,HCPCS,Outpatient,,,5200,3120,,936,18,,,percent of total billed charges,pays at 18% of total charges,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,936,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3640,70,,,percent of total billed charges,70% of total billed charges,3900,75,,,percent of total billed charges,75% of total billed charges,2600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3978,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,895.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2340,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1976,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2496,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4680,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.84,5200,
PACER GEN DUAL RATE RESPONSE,4123160,CDM,275,RC,C1785,HCPCS,Outpatient,,,5200,3120,,936,18,,,percent of total billed charges,pays at 18% of total charges,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,936,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3640,70,,,percent of total billed charges,70% of total billed charges,3900,75,,,percent of total billed charges,75% of total billed charges,2600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3978,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,895.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2340,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1976,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3640,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2496,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4680,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,814.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.84,5200,
PACER GEN DUAL RATE RESPONSE,4123161,CDM,275,RC,C1785,HCPCS,Outpatient,,,6500,3900,,1170,18,,,percent of total billed charges,pays at 18% of total charges,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1170,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550,70,,,percent of total billed charges,70% of total billed charges,4875,75,,,percent of total billed charges,75% of total billed charges,3250,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4972.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1119.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2925,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3900,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2470,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4550,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3120,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5850,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1018.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1018.55,6500,
PACER GEN DUAL RATE RESPONSE,4123162,CDM,275,RC,C1785,HCPCS,Outpatient,,,7800,4680,,1404,18,,,percent of total billed charges,pays at 18% of total charges,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1404,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5460,70,,,percent of total billed charges,70% of total billed charges,5850,75,,,percent of total billed charges,75% of total billed charges,3900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5967,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1343.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3510,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2964,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7020,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.26,7800,
PACER GEN BI VENT,4123163,CDM,275,RC,C2621,HCPCS,Outpatient,,,9100,5460,,1638,18,,,percent of total billed charges,pays at 18% of total charges,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1638,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6370,70,,,percent of total billed charges,70% of total billed charges,6825,75,,,percent of total billed charges,75% of total billed charges,4550,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5460,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6961.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1567.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4095,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6370,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5460,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3458,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6370,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4368,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8190,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1425.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.97,9100,
PACER GEN BI VENT,4123164,CDM,275,RC,C2621,HCPCS,Outpatient,,,10400,6240,,1872,18,,,percent of total billed charges,pays at 18% of total charges,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1872,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7280,70,,,percent of total billed charges,70% of total billed charges,7800,75,,,percent of total billed charges,75% of total billed charges,5200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7956,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1791.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4680,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3952,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4992,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1629.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1629.68,10400,
ICD GEN SINGLE,4123165,CDM,278,RC,C1722,HCPCS,Outpatient,,,16900,10140,,3042,18,,,percent of total billed charges,pays at 18% of total charges,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3042,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11830,70,,,percent of total billed charges,70% of total billed charges,12675,75,,,percent of total billed charges,75% of total billed charges,8450,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,13520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10140,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16900,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2911.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7605,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11830,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10140,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6422,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,11830,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8112,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,16900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16900,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2648.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2648.23,16900,
ICD GEN SINGLE,4123166,CDM,278,RC,C1722,HCPCS,Outpatient,,,18200,10920,,3276,18,,,percent of total billed charges,pays at 18% of total charges,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3276,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12740,70,,,percent of total billed charges,70% of total billed charges,13650,75,,,percent of total billed charges,75% of total billed charges,9100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18200,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3135.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8190,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12740,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6916,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12740,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8736,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2851.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2851.94,18200,
ICD GEN SINGLE,4123167,CDM,278,RC,C1722,HCPCS,Outpatient,,,19500,11700,,3510,18,,,percent of total billed charges,pays at 18% of total charges,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3510,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13650,70,,,percent of total billed charges,70% of total billed charges,14625,75,,,percent of total billed charges,75% of total billed charges,9750,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11700,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19500,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3359.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8775,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13650,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11700,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7410,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13650,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9360,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19500,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3055.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3055.65,19500,
ICD GEN DUAL,4123168,CDM,278,RC,C1721,HCPCS,Outpatient,,,20800,12480,,3744,18,,,percent of total billed charges,pays at 18% of total charges,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3744,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14560,70,,,percent of total billed charges,70% of total billed charges,15600,75,,,percent of total billed charges,75% of total billed charges,10400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3583.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9360,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7904,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9984,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3259.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3259.36,20800,
ICD GEN DUAL,4123169,CDM,278,RC,C1721,HCPCS,Outpatient,,,22100,13260,,3978,18,,,percent of total billed charges,pays at 18% of total charges,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3978,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15470,70,,,percent of total billed charges,70% of total billed charges,16575,75,,,percent of total billed charges,75% of total billed charges,11050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22100,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3807.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8398,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10608,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3463.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3463.07,22100,
ICD GEN BI VENT,4123170,CDM,278,RC,C1882,HCPCS,Outpatient,,,24700,14820,,4446,18,,,percent of total billed charges,pays at 18% of total charges,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4446,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17290,70,,,percent of total billed charges,70% of total billed charges,18525,75,,,percent of total billed charges,75% of total billed charges,12350,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19760,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14820,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24700,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4255.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11115,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17290,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14820,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9386,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17290,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11856,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,24700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,24700,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3870.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3870.49,24700,
ICD GEN BI VENT,4123171,CDM,278,RC,C1882,HCPCS,Outpatient,,,26000,15600,,4680,18,,,percent of total billed charges,pays at 18% of total charges,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4680,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18200,70,,,percent of total billed charges,70% of total billed charges,19500,75,,,percent of total billed charges,75% of total billed charges,13000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26000,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4479.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11700,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9880,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,18200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12480,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4074.2,26000,
ICD GEN BI VENT,4123172,CDM,278,RC,C1882,HCPCS,Outpatient,,,27950,16770,,5031,18,,,percent of total billed charges,pays at 18% of total charges,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5031,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19565,70,,,percent of total billed charges,70% of total billed charges,20962.5,75,,,percent of total billed charges,75% of total billed charges,13975,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,22360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16770,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27950,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4815.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12577.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19565,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16770,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10621,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19565,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13416,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,27950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27950,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4379.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4379.77,27950,
AAA STENT GRAFT CONTRALATERAL,4123173,CDM,278,RC,,,Outpatient,,,7800,4680,,1404,18,,,percent of total billed charges,pays at 18% of total charges,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1404,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3900,50,,,percent of total billed charges,pays at 50% of total billed charges,5460,70,,,percent of total billed charges,70% of total billed charges,5850,75,,,percent of total billed charges,75% of total billed charges,3900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3510,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2964,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.26,7800,
CATHETER ATHERECTOMY ROTATIONAL,4123174,CDM,272,RC,C1724,HCPCS,Outpatient,,,4933.5,2960.1,,888.03,18,,,percent of total billed charges,pays at 18% of total charges,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,888.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3453.45,70,,,percent of total billed charges,70% of total billed charges,3700.13,75,,,percent of total billed charges,75% of total billed charges,2466.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3946.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2960.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3774.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,850.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2220.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3453.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2960.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1874.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3453.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2368.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4933.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4440.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,773.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.08,4933.5,
PTA DCB > 100CM - 150CM,4123175,CDM,272,RC,C2623,HCPCS,Outpatient,,,2327,1396.2,,418.86,18,,,percent of total billed charges,pays at 18% of total charges,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1628.9,70,,,percent of total billed charges,70% of total billed charges,1745.25,75,,,percent of total billed charges,75% of total billed charges,1163.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1861.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1396.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1780.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,400.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1628.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1396.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,884.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1628.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2327,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2094.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.64,2327,
PTA DRUG COATED BALLOON <= 100MM,4123176,CDM,272,RC,C2623,HCPCS,Outpatient,,,1937,1162.2,,348.66,18,,,percent of total billed charges,pays at 18% of total charges,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1355.9,70,,,percent of total billed charges,70% of total billed charges,1452.75,75,,,percent of total billed charges,75% of total billed charges,968.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1549.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1162.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1481.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,333.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,871.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1355.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1162.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,736.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1355.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,929.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1937,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1743.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,303.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.53,1937,
PACER LEAD EXTENDER/ ADAPT KIT,4123177,CDM,272,RC,,,Outpatient,,,277.5,166.5,,49.95,18,,,percent of total billed charges,pays at 18% of total charges,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.75,50,,,percent of total billed charges,pays at 50% of total billed charges,194.25,70,,,percent of total billed charges,70% of total billed charges,208.13,75,,,percent of total billed charges,75% of total billed charges,138.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,222,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,249.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.48,277.5,
PERIPHERAL STENT PLCMNT VERTEBRAL UNI,4123178,CDM,481,RC,37236,HCPCS,Outpatient,,,10625,6375,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7437.5,70,,,percent of total billed charges,70% of total billed charges,7968.75,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,8128.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1830.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4781.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7437.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6375,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7437.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5100,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9562.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1664.94,34162.33,
STENT INNOMINATE/INTRTHOR COMM CAROTID,4123179,CDM,481,RC,37218,HCPCS,Outpatient,,,10119.26,6071.56,,10119.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10119.26,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5059.63,50,,,percent of total billed charges,pays at 50% of total billed charges,7083.48,70,,,percent of total billed charges,70% of total billed charges,7589.45,75,,,percent of total billed charges,75% of total billed charges,10119.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8095.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10119.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7741.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1743.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4553.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7083.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6071.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7083.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4857.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9107.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10119.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,10119.26,
ATHERECTOMY ILIAC UNILATERAL,4123180,CDM,481,RC,0238T,HCPCS,Outpatient,,,17007.3,10204.38,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32663.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,11905.11,70,,,percent of total billed charges,70% of total billed charges,12755.48,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,13605.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,13010.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2930.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,7653.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,11905.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10204.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,11905.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,8163.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15306.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2665.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,2665.04,55281.18,
"Incision and drainage of hematoma, seroma or fluid collection",4123181,CDM,761,RC,10140,HCPCS,Outpatient,,,2062.6,1237.56,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2062.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1546.95,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1650.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1577.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,928.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1443.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1237.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,783.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1443.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,990.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1856.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2062.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,783.79,4825.85,
CATHETER - STEERABLE PERI/EP,4123182,CDM,272,RC,C1887,HCPCS,Outpatient,,,947.7,568.62,,170.59,18,,,percent of total billed charges,pays at 18% of total charges,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,170.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.78,75,,,percent of total billed charges,75% of total billed charges,473.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,758.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,724.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,163.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,663.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,663.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,947.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,852.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,148.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,947.7,
SHEATH - GUIDING STEERABLE PERI,4123183,CDM,272,RC,C1766,HCPCS,Outpatient,,,747.5,448.5,,134.55,18,,,percent of total billed charges,pays at 18% of total charges,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,134.55,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.25,70,,,percent of total billed charges,70% of total billed charges,560.63,75,,,percent of total billed charges,75% of total billed charges,373.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,598,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,448.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,571.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,523.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,448.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,284.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,523.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,747.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,672.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.13,747.5,
THROMBECT PERI MECH INT VENOUS,4123184,CDM,481,RC,37187,HCPCS,Outpatient,,,6648.4,3989.04,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6648.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9745.74,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4653.88,70,,,percent of total billed charges,70% of total billed charges,4986.3,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5318.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,6648.4,103,,,Fee Schedule,103% of CMS OPPS Rate,5086.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1145.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2991.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4653.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3989.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4653.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3191.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6648.4,100,,,Fee Schedule,100% of CMS OPPS Rate,5983.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1041.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1041.8,34162.33,
THROMBECT PERI MECH SUBSQ VENOUS,4123185,CDM,481,RC,37188,HCPCS,Outpatient,,,3311.2,1986.72,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2317.84,70,,,percent of total billed charges,70% of total billed charges,2483.4,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2648.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2533.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,570.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1490.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2317.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1986.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2317.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1589.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2980.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,518.87,9586.95,
STENT CERV CAROTID W EMBOLIC PROTECT,4123186,CDM,481,RC,37215,HCPCS,Outpatient,,,10625,6375,,10625,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10625,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,18215.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7437.5,70,,,percent of total billed charges,70% of total billed charges,7968.75,75,,,percent of total billed charges,75% of total billed charges,10625,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8500,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,10625,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8128.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1830.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,4781.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7437.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6375,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7437.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5100,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,9562.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1664.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,10625,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,18215.31,
STENT CERV CAROTID W/O EMBOLIC PROTECT,4123187,CDM,481,RC,37216,HCPCS,Outpatient,,,10119.26,6071.56,,1821.47,18,,,percent of total billed charges,pays at 18% of total charges,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1821.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5059.63,50,,,percent of total billed charges,pays at 50% of total billed charges,7083.48,70,,,percent of total billed charges,70% of total billed charges,7589.45,75,,,percent of total billed charges,75% of total billed charges,5059.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8095.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6071.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7741.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1743.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4553.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7083.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6071.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7083.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4857.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10119.26,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9107.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1585.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1571,10119.26,
INSERTION SWAN GANZ ONLY,4123188,CDM,481,RC,93503,HCPCS,Outpatient,,,1509.22,905.53,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1056.45,70,,,percent of total billed charges,70% of total billed charges,1131.92,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1207.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1154.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,260.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,679.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1056.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,905.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1056.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,724.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1358.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,236.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,236.49,4788.21,
PTA ARTERY AORTA/RENAL/VISCERAL,4123189,CDM,481,RC,37246,HCPCS,Outpatient,,,13409,8045.4,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13409,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7879.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges,10056.75,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10727.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,10257.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,6034.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8045.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9386.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6436.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,12068.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13409,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,16784.25,
PTA ARTERY AORTA/RENAL/VISCERAL ADD VSSL,4123190,CDM,481,RC,37247,HCPCS,Outpatient,,,5897,3538.2,,1061.46,18,,,percent of total billed charges,pays at 18% of total charges,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1061.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4127.9,70,,,percent of total billed charges,70% of total billed charges,4422.75,75,,,percent of total billed charges,75% of total billed charges,2948.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4717.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3538.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4511.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2653.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4127.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3538.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4127.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2830.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5897,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5307.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,924.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,5897,
PTA  VENOUS  ADD VESSEL,4123191,CDM,481,RC,37249,HCPCS,Outpatient,,,4158,2494.8,,748.44,18,,,percent of total billed charges,pays at 18% of total charges,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,748.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2910.6,70,,,percent of total billed charges,70% of total billed charges,3118.5,75,,,percent of total billed charges,75% of total billed charges,2079,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2494.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3180.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,716.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1871.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2910.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2494.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2910.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1995.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4158,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3742.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,651.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.56,4158,
PLACMT EXT PROSTH PROX/DIST AORT ILIAC D,4123192,CDM,481,RC,34710,HCPCS,Outpatient,,,1196.64,717.98,,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,598.32,50,,,percent of total billed charges,pays at 50% of total billed charges,837.65,70,,,percent of total billed charges,70% of total billed charges,897.48,75,,,percent of total billed charges,75% of total billed charges,1196.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,957.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,915.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,206.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,538.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,717.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,574.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,187.51,1571,
PLACMT EXT PROS PROX/DIS AORT ILIAC ADD,4123193,CDM,481,RC,34711,HCPCS,Outpatient,,,1196.64,717.98,,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,598.32,50,,,percent of total billed charges,pays at 50% of total billed charges,837.65,70,,,percent of total billed charges,70% of total billed charges,897.48,75,,,percent of total billed charges,75% of total billed charges,1196.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,957.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,915.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,206.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,538.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,717.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,574.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,187.51,1571,
TRANSCATH DELIVERY FIXATION DEVICE,4123194,CDM,481,RC,34712,HCPCS,Outpatient,,,1196.64,717.98,,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,598.32,50,,,percent of total billed charges,pays at 50% of total billed charges,837.65,70,,,percent of total billed charges,70% of total billed charges,897.48,75,,,percent of total billed charges,75% of total billed charges,1196.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,957.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,915.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,206.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,538.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,717.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,837.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,574.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1076.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.64,100,,,Fee Schedule,100% of CMS OPPS Rate,187.51,1571,
PERC CLOSURE FEM ART 12 FR + UNILATERAL,4123195,CDM,481,RC,34713,HCPCS,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,657,
GUIDEWIRE VALVULOPLASTY,4123196,CDM,272,RC,C1769,HCPCS,Outpatient,,,819,491.4,,147.42,18,,,percent of total billed charges,pays at 18% of total charges,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,147.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.25,75,,,percent of total billed charges,75% of total billed charges,409.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,655.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,626.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,491.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,311.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,573.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,819,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,737.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.34,819,
STOPCOCK HI PRESSURE,4123197,CDM,272,RC,,,Outpatient,,,9,5.4,,1.62,18,,,percent of total billed charges,pays at 18% of total charges,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.5,50,,,percent of total billed charges,pays at 50% of total billed charges,6.3,70,,,percent of total billed charges,70% of total billed charges,6.75,75,,,percent of total billed charges,75% of total billed charges,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,9,
INTRODUCER SHEATH CORONARY,4123198,CDM,272,RC,C1893,HCPCS,Outpatient,,,55,33,,9.9,18,,,percent of total billed charges,pays at 18% of total charges,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.5,70,,,percent of total billed charges,70% of total billed charges,41.25,75,,,percent of total billed charges,75% of total billed charges,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,55,
GUIDEWIRE DIAGNOSTIC,4123199,CDM,272,RC,C1769,HCPCS,Outpatient,,,76.34,45.8,,13.74,18,,,percent of total billed charges,pays at 18% of total charges,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.26,75,,,percent of total billed charges,75% of total billed charges,38.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,68.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,76.34,
CATH DIAGNOSTICS,4123200,CDM,272,RC,C1887,HCPCS,Outpatient,,,22.35,13.41,,4.02,18,,,percent of total billed charges,pays at 18% of total charges,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,75,,,percent of total billed charges,75% of total billed charges,11.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,17.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,15.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,20.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,22.35,
GUIDEWIRE WHOLLEY,4123201,CDM,272,RC,C1769,HCPCS,Outpatient,,,95,57,,17.1,18,,,percent of total billed charges,pays at 18% of total charges,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.25,75,,,percent of total billed charges,75% of total billed charges,47.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,66.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,85.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,95,
LEADS CARDIAC DISP,4123202,CDM,270,RC,,,Outpatient,,,42.5,25.5,,7.65,18,,,percent of total billed charges,pays at 18% of total charges,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.25,50,,,percent of total billed charges,pays at 50% of total billed charges,29.75,70,,,percent of total billed charges,70% of total billed charges,31.88,75,,,percent of total billed charges,75% of total billed charges,21.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,29.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,42.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,38.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.66,42.5,
INSERT/REPLACE SQ S-ICD & EVALUATION,4123203,CDM,481,RC,33270,HCPCS,Outpatient,,,72731.52,43638.91,,103228.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,29160.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61866.12,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,50912.06,70,,,percent of total billed charges,70% of total billed charges,54548.64,75,,,percent of total billed charges,75% of total billed charges,52489.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58185.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102062.06,350,,,Fee Schedule,350% of CMS OPPS Rate,29743.79,103,,,Fee Schedule,103% of CMS OPPS Rate,55639.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12531.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,32729.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50912.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43638.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4577,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,50912.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,67069.35,100,,,Fee Schedule,100% of CMS OPPS Rate,34911.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,65458.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11397.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,29160.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4577,103228.48,
INSERT SQ S-ICD LEAD,4123204,CDM,481,RC,33271,HCPCS,Outpatient,,,26553.39,15932.03,,26269.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26553.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7420.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15028.71,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,18587.37,70,,,percent of total billed charges,70% of total billed charges,19915.04,75,,,percent of total billed charges,75% of total billed charges,13357.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,21242.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25972.7,350,,,Fee Schedule,350% of CMS OPPS Rate,7569.18,103,,,Fee Schedule,103% of CMS OPPS Rate,20313.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11949.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18587.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15932.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,18587.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17067.78,100,,,Fee Schedule,100% of CMS OPPS Rate,12745.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,23898.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26553.39,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7420.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,26553.39,
REMOVAL S-ICD LEAD,4123205,CDM,481,RC,33272,HCPCS,Outpatient,,,5539.49,3323.69,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3877.64,70,,,percent of total billed charges,70% of total billed charges,4154.62,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4431.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.25,103,,,Fee Schedule,103% of CMS OPPS Rate,4237.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,954.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2492.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3877.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3323.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3877.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2658.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,4985.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,868.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,868.04,10784,
REPOSITION SQ S-ICD LEAD,4123206,CDM,481,RC,33273,HCPCS,Outpatient,,,5539.49,3323.69,,10784,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5539.49,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3046.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5847.46,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3877.64,70,,,percent of total billed charges,70% of total billed charges,4154.62,75,,,percent of total billed charges,75% of total billed charges,5483.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4431.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10662.15,350,,,Fee Schedule,350% of CMS OPPS Rate,3107.24,103,,,Fee Schedule,103% of CMS OPPS Rate,4237.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2492.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3877.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3323.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3877.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2658.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,4985.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5539.49,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,10784,
S-ICD SQ GENERATOR,4123207,CDM,278,RC,C1722,HCPCS,Outpatient,,,26000,15600,,4680,18,,,percent of total billed charges,pays at 18% of total charges,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4680,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18200,70,,,percent of total billed charges,70% of total billed charges,19500,75,,,percent of total billed charges,75% of total billed charges,13000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26000,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4479.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11700,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,18200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9880,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,18200,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12480,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4074.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4074.2,26000,
S-ICD SQ LEAD,4123208,CDM,278,RC,C1896,HCPCS,Outpatient,,,7800,4680,,1404,18,,,percent of total billed charges,pays at 18% of total charges,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1404,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5460,70,,,percent of total billed charges,70% of total billed charges,5850,75,,,percent of total billed charges,75% of total billed charges,3900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,6240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7800,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1343.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3510,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2964,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5460,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1222.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.26,7800,
EMBOILIZATION MICRO VASCULAR PLUG,4123209,CDM,272,RC,,,Outpatient,,,2405,1443,,432.9,18,,,percent of total billed charges,pays at 18% of total charges,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1683.5,70,,,percent of total billed charges,70% of total billed charges,1803.75,75,,,percent of total billed charges,75% of total billed charges,1202.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1924,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1443,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1683.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1443,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1683.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1154.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2405,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2164.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.86,2405,
VASCULAR CLOSURE DEVICE LARGE,4123210,CDM,278,RC,C1760,HCPCS,Outpatient,,,1625,975,,292.5,18,,,percent of total billed charges,pays at 18% of total charges,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,292.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.5,70,,,percent of total billed charges,70% of total billed charges,1218.75,75,,,percent of total billed charges,75% of total billed charges,812.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,975,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1625,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,279.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,975,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,617.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1137.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1625,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.64,1625,
INSERT/REPLACE PACER LEADLESS SINGLE,4123211,CDM,481,RC,33274,HCPCS,Outpatient,,,48896,29337.6,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48896,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31306.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,34227.2,70,,,percent of total billed charges,70% of total billed charges,36672,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,39116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,37405.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,22003.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34227.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29337.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,34227.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,23470.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,44006.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,55281.18,
REMOVE PACER LEADLESS SINGLE,4123212,CDM,481,RC,33275,HCPCS,Outpatient,,,11246,6747.6,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11246,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5385.8,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7872.2,70,,,percent of total billed charges,70% of total billed charges,8434.5,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8996.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,8603.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5060.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7872.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6747.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7872.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,5398.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,10121.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11246,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,11246,
LEADLESS PACER SINGLE GENERATOR,4123213,CDM,275,RC,C1786,HCPCS,Outpatient,,,11895,7137,,2141.1,18,,,percent of total billed charges,pays at 18% of total charges,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2141.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8326.5,70,,,percent of total billed charges,70% of total billed charges,8921.25,75,,,percent of total billed charges,75% of total billed charges,5947.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9516,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7137,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9099.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2049.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5352.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8326.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7137,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4520.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8326.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5709.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11895,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10705.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1863.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1863.95,11895,
LEADLESS PACER SHEATH,4123214,CDM,272,RC,C1894,HCPCS,Outpatient,,,780,468,,140.4,18,,,percent of total billed charges,pays at 18% of total charges,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546,70,,,percent of total billed charges,70% of total billed charges,585,75,,,percent of total billed charges,75% of total billed charges,390,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,624,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,596.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,134.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,780,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,702,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.23,780,
INSERT/REPLACE PACER LEADLESS DUAL,4123215,CDM,481,RC,33274,HCPCS,Outpatient,,,48896,29337.6,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48896,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31306.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,34227.2,70,,,percent of total billed charges,70% of total billed charges,36672,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,39116.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,37405.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,22003.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34227.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29337.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,34227.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,23470.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,44006.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,48896,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,55281.18,
LEADLESS PACER DUAL GENERATOR,4123216,CDM,275,RC,C1785,HCPCS,Outpatient,,,19695,11817,,3545.1,18,,,percent of total billed charges,pays at 18% of total charges,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3545.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13786.5,70,,,percent of total billed charges,70% of total billed charges,14771.25,75,,,percent of total billed charges,75% of total billed charges,9847.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15756,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11817,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15066.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3393.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8862.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13786.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11817,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7484.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13786.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9453.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19695,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17725.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3086.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3086.21,19695,
DEBRIDEMENT SQ TISSUE,4123217,CDM,481,RC,11042,HCPCS,Outpatient,,,1003.52,602.11,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1003.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,702.46,70,,,percent of total billed charges,70% of total billed charges,752.64,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,802.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,767.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,451.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,702.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,602.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,702.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,481.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,903.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1003.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,1200.6,
ALCHOL SEPTAL  ABLATION W TEMP.PACER,4123218,CDM,481,RC,93583,HCPCS,Outpatient,,,3000,1800,,3000,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3000,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1500,50,,,percent of total billed charges,pays at 50% of total billed charges,2100,70,,,percent of total billed charges,70% of total billed charges,2250,75,,,percent of total billed charges,75% of total billed charges,3000,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3000,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2295,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,516.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,1350,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2100,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1440,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,2700,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,100,,,Fee Schedule,100% of CMS OPPS Rate,470.1,3000,
REMOVE LV ASSIST/ TRANSEPTAL,4123219,CDM,481,RC,33992,HCPCS,Outpatient,,,9190,5514,,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9190,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4595,50,,,percent of total billed charges,pays at 50% of total billed charges,6433,70,,,percent of total billed charges,70% of total billed charges,6892.5,75,,,percent of total billed charges,75% of total billed charges,9190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,7352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7030.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1583.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,4135.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6433,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5514,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,6433,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4411.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,8271,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,1440.07,9190,
INTRAVAS LITHOTRIP LOW EXT NOT TP wPTA,4123220,CDM,481,RC,C9764,HCPCS,Outpatient,,,11173.55,6704.13,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5586.78,50,,,percent of total billed charges,pays at 50% of total billed charges,7821.49,70,,,percent of total billed charges,70% of total billed charges,8380.16,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8938.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,8547.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1925.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5028.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7821.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6704.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7821.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5363.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10056.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1750.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,1750.9,34162.33,
INTRAVAS LITHOTRIP LOW EXT NOT TP wSTENT,4123221,CDM,481,RC,C9765,HCPCS,Outpatient,,,22348.58,13409.15,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11174.29,50,,,percent of total billed charges,pays at 50% of total billed charges,15644.01,70,,,percent of total billed charges,70% of total billed charges,16761.44,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,17878.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,17096.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3850.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10056.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15644.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13409.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,15644.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10727.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20113.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3502.02,55281.18,
INTRAVAS LITHOTRIP LOW EXT NOT TP w ATHR,4123222,CDM,481,RC,C9766,HCPCS,Outpatient,,,22348.58,13409.15,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11174.29,50,,,percent of total billed charges,pays at 50% of total billed charges,15644.01,70,,,percent of total billed charges,70% of total billed charges,16761.44,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,17878.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,17096.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3850.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,10056.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15644.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13409.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,15644.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,10727.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,20113.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3502.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3502.02,55281.18,
INTRVS LITHO LOW EXT NOT TP w ATHRE/STNT,4123223,CDM,481,RC,C9767,HCPCS,Outpatient,,,35952.5,21571.5,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17976.25,50,,,percent of total billed charges,pays at 50% of total billed charges,25166.75,70,,,percent of total billed charges,70% of total billed charges,26964.38,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,28762,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,27503.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6194.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,16178.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25166.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21571.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,25166.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,17257.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32357.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5633.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,55281.18,
INTRAVASC LITHO PERI CATH,4123224,CDM,272,RC,,,Outpatient,,,4485,2691,,807.3,18,,,percent of total billed charges,pays at 18% of total charges,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,807.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2242.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3139.5,70,,,percent of total billed charges,70% of total billed charges,3363.75,75,,,percent of total billed charges,75% of total billed charges,2242.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3588,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2691,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3431.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2018.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3139.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2691,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1704.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3139.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2152.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4485,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4036.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,702.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.8,4485,
INTRAVAS LITHOTRIPSY TIB/PERONEAL wPTA,4123225,CDM,481,RC,C9772,HCPCS,Outpatient,,,22736.2,13641.72,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11368.1,50,,,percent of total billed charges,pays at 50% of total billed charges,15915.34,70,,,percent of total billed charges,70% of total billed charges,17052.15,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,18188.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,17393.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3917.45,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10231.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,15915.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13641.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,15915.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,10913.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,20462.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3562.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3562.76,34162.33,
INTRAVAS LITHOTRIPSY TIB/PERONEAL wSTENT,4123226,CDM,481,RC,C9773,HCPCS,Outpatient,,,36367.3,21820.38,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18183.65,50,,,percent of total billed charges,pays at 50% of total billed charges,25457.11,70,,,percent of total billed charges,70% of total billed charges,27275.48,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29093.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,27820.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6266.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,16365.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25457.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21820.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,25457.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,17456.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32730.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,55281.18,
INTRAVAS LITHOTRIP TIB/PERONEAL wATHREC,4123227,CDM,481,RC,C9774,HCPCS,Outpatient,,,36367.3,21820.38,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18183.65,50,,,percent of total billed charges,pays at 50% of total billed charges,25457.11,70,,,percent of total billed charges,70% of total billed charges,27275.48,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29093.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,27820.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6266.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,16365.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25457.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21820.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,25457.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,17456.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32730.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,55281.18,
INTRAVS LITHOTRIP TIB/PERON wATHREC/STNT,4123228,CDM,481,RC,C9775,HCPCS,Outpatient,,,36367.3,21820.38,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18183.65,50,,,percent of total billed charges,pays at 50% of total billed charges,25457.11,70,,,percent of total billed charges,70% of total billed charges,27275.48,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29093.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,27820.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6266.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,16365.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25457.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21820.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,25457.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,17456.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,32730.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5698.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,55281.18,
LV ASSIST LARGE SHEATH KIT,4123229,CDM,272,RC,C1894,HCPCS,Outpatient,,,910,546,,163.8,18,,,percent of total billed charges,pays at 18% of total charges,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,637,70,,,percent of total billed charges,70% of total billed charges,682.5,75,,,percent of total billed charges,75% of total billed charges,455,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,546,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,696.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,637,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,546,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,345.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,637,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,910,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,819,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.6,910,
INTRAVASC LITHO CORO CATH,4123230,CDM,272,RC,C1761,HCPCS,Outpatient,,,6110,3666,,1099.8,18,,,percent of total billed charges,pays at 18% of total charges,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1099.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3055,50,,,percent of total billed charges,pays at 50% of total billed charges,4277,70,,,percent of total billed charges,70% of total billed charges,4582.5,75,,,percent of total billed charges,75% of total billed charges,3055,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4888,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3666,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4674.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1052.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2749.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4277,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3666,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2321.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4277,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2932.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6110,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5499,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,957.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.44,6110,
PTA DCB > 150CM,4123231,CDM,272,RC,C2623,HCPCS,Outpatient,,,3211,1926.6,,577.98,18,,,percent of total billed charges,pays at 18% of total charges,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,577.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247.7,70,,,percent of total billed charges,70% of total billed charges,2408.25,75,,,percent of total billed charges,75% of total billed charges,1605.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2568.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1926.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2456.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,553.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1444.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2247.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1926.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1220.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2247.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1541.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3211,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2889.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,503.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.16,3211,
AAA SHEATH 33CM,4123232,CDM,272,RC,C1894,HCPCS,Outpatient,,,845,507,,152.1,18,,,percent of total billed charges,pays at 18% of total charges,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.5,70,,,percent of total billed charges,70% of total billed charges,633.75,75,,,percent of total billed charges,75% of total billed charges,422.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,676,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,507,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,646.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,145.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,591.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,507,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,321.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,591.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,845,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,760.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.41,845,
AAA SHEATH 45CM - 65CM,4123233,CDM,272,RC,C1894,HCPCS,Outpatient,,,1102.4,661.44,,198.43,18,,,percent of total billed charges,pays at 18% of total charges,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.68,70,,,percent of total billed charges,70% of total billed charges,826.8,75,,,percent of total billed charges,75% of total billed charges,551.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,881.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1102.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,992.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.75,1102.4,
PANNUS RETENT UNSTERILE,4123234,CDM,270,RC,,,Outpatient,,,82,49.2,,14.76,18,,,percent of total billed charges,pays at 18% of total charges,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,41,50,,,percent of total billed charges,pays at 50% of total billed charges,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,41,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.85,82,
RV ASSIST INSERT VENOUS,4123235,CDM,481,RC,33995,HCPCS,Outpatient,,,15267.63,9160.58,,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15267.63,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7633.82,50,,,percent of total billed charges,pays at 50% of total billed charges,10687.34,70,,,percent of total billed charges,70% of total billed charges,11450.72,75,,,percent of total billed charges,75% of total billed charges,15267.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,12214.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,11679.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2630.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,6870.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10687.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9160.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,10687.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7328.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,13740.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2392.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,15267.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,15267.63,
REMOVAL RV ASSIST VENOUS,4123236,CDM,481,RC,33997,HCPCS,Outpatient,,,9190,5514,,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9190,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4595,50,,,percent of total billed charges,pays at 50% of total billed charges,6433,70,,,percent of total billed charges,70% of total billed charges,6892.5,75,,,percent of total billed charges,75% of total billed charges,9190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,7352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7030.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1583.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,4135.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6433,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5514,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,6433,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4411.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,8271,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1440.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,9190,100,,,Fee Schedule,100% of CMS OPPS Rate,1440.07,9190,
LV ASSIST PURGE KIT,41253237,CDM,272,RC,,,Outpatient,,,300,180,,54,18,,,percent of total billed charges,pays at 18% of total charges,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150,50,,,percent of total billed charges,pays at 50% of total billed charges,210,70,,,percent of total billed charges,70% of total billed charges,225,75,,,percent of total billed charges,75% of total billed charges,150,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,229.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,300,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.01,300,
HYDRATION INFUSION INITIAL HR,4126360,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,4126361,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",4126365,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",4126366,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,4126367,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,4126368,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,4126369,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",4126374,CDM,260,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",4126375,CDM,260,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,23.35,334,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",4126376,CDM,260,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,334,
CARDIAC REHAB PRODUCTIVITY ONLY,4130001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
CARDIAC REHAB W/O CONT ECG,4131400,CDM,943,RC,93797,HCPCS,Outpatient,,,298,178.8,,386.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,109.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,109.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,237.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,208.6,70,,,percent of total billed charges,70% of total billed charges,223.5,75,,,percent of total billed charges,75% of total billed charges,196.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.04,350,,,Fee Schedule,350% of CMS OPPS Rate,111.33,103,,,Fee Schedule,103% of CMS OPPS Rate,227.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,244,100,,,Case rate,Pays based on per visit ,208.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,251.05,100,,,Fee Schedule,100% of CMS OPPS Rate,143.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,268.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,386.4,
Use of EKG to monitor cardiac rehabilitation,4131479,CDM,943,RC,93798,HCPCS,Outpatient,,,298,178.8,,386.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,109.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,109.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,237.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,208.6,70,,,percent of total billed charges,70% of total billed charges,223.5,75,,,percent of total billed charges,75% of total billed charges,196.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,238.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,382.04,350,,,Fee Schedule,350% of CMS OPPS Rate,111.33,103,,,Fee Schedule,103% of CMS OPPS Rate,227.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,244,100,,,Case rate,Pays based on per visit ,208.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,251.05,100,,,Fee Schedule,100% of CMS OPPS Rate,143.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,268.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of CMS OPPS Rate,109.15,386.4,
CARDIAC RECONDTIONING ACT,4131480,CDM,943,RC,,,Outpatient,,,144.36,86.62,,25.98,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,25.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.18,50,,,percent of total billed charges,pays at 50% of total billed charges,101.05,70,,,percent of total billed charges,70% of total billed charges,108.27,75,,,percent of total billed charges,75% of total billed charges,72.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,101.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244,100,,,Case rate,Pays based on per visit ,101.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.98,244,
PERIPHERAL ARTERIAL DISEASE REHAB,4131481,CDM,943,RC,93668,HCPCS,Outpatient,,,119.33,71.6,,184.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,83.53,70,,,percent of total billed charges,70% of total billed charges,89.5,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,95.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.29,103,,,Fee Schedule,103% of CMS OPPS Rate,91.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,53.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,244,100,,,Case rate,Pays based on per visit ,83.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,57.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,107.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,244,
CARDIAC REHAB CONSULT,4132011,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Outpatient visit of established patient requiring a physician,4139000,CDM,510,RC,99212,HCPCS,Outpatient,,,152,91.2,,27.36,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,152,
INJECTION SQ OR IM,4139001,CDM,510,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
Draining or injecting medication into a small joint/bursa without ultrasound,4139002,CDM,510,RC,20600,HCPCS,Outpatient,,,800,480,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,612,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,360,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,384,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,720,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,125.36,875,
Draining or injecting medication into a large joint/bursa without ultrasound,4139003,CDM,510,RC,20605,HCPCS,Outpatient,,,800,480,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,612,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,360,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,384,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,720,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,125.36,875,
Draining or injecting medication into a major joint/bursa without ultrasound,4139004,CDM,510,RC,20610,HCPCS,Outpatient,,,800,480,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,600,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,612,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,137.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,360,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,384,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,720,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,125.36,875,
Sleep monitoring of patient (6 years or older) in sleep lab,4141000,CDM,920,RC,95810,HCPCS,Outpatient,,,4704.48,2822.69,,3007.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3293.14,70,,,percent of total billed charges,70% of total billed charges,3528.36,75,,,percent of total billed charges,75% of total billed charges,1528.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3763.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2973.05,350,,,Fee Schedule,350% of CMS OPPS Rate,866.42,103,,,Fee Schedule,103% of CMS OPPS Rate,3598.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,810.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2117.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3293.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2822.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,3293.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,4234.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,737.19,4234.03,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,4141001,CDM,920,RC,95811,HCPCS,Outpatient,,,4704.48,2822.69,,3007.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3293.14,70,,,percent of total billed charges,70% of total billed charges,3528.36,75,,,percent of total billed charges,75% of total billed charges,1528.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3763.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2973.05,350,,,Fee Schedule,350% of CMS OPPS Rate,866.42,103,,,Fee Schedule,103% of CMS OPPS Rate,3598.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,810.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2117.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3293.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2822.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,3293.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2258.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,4234.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,737.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,737.19,4234.03,
POLYSOMNOGRAPH W/MSLT,4141002,CDM,920,RC,95805,HCPCS,Outpatient,,,2799.36,1679.62,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1959.55,70,,,percent of total billed charges,70% of total billed charges,2099.52,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2239.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,2141.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1259.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1959.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1679.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,1959.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1343.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,2519.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,438.66,2519.42,
POLYSOM THREAPUTIC ADJ.,4141004,CDM,920,RC,95807,HCPCS,Outpatient,,,1221.12,732.67,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,854.78,70,,,percent of total billed charges,70% of total billed charges,915.84,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,976.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,934.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,549.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,854.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,732.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,854.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,586.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1099.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,191.35,1599,
"SLEEP STUDY, UNATTENDED",4141008,CDM,510,RC,95806,HCPCS,Outpatient,,,900,540,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,688.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,405,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,432,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,810,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,810,
"SLEEP STUDY, UNATTENDED",4141010,CDM,510,RC,95800,HCPCS,Outpatient,,,900,540,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,688.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,405,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,432,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,810,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,810,
"SLEEP STUDY, UNATTENDED",4141011,CDM,510,RC,G0399,HCPCS,Outpatient,,,900,540,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,688.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,405,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,432,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,810,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,810,
Sleep monitoring of patient (6 years or older) in sleep lab,4141012,CDM,510,RC,95810,HCPCS,Outpatient,,,2460,1476,,3007.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1845,75,,,percent of total billed charges,75% of total billed charges,1528.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1968,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2973.05,350,,,Fee Schedule,350% of CMS OPPS Rate,866.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1881.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,423.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1107,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1722,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1476,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1722,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1180.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,2214,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,385.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,385.48,3007.03,
POLYSOM THREAP ADJ RED SV,4141013,CDM,920,RC,95807,HCPCS,Outpatient,,,839.88,503.93,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,587.92,70,,,percent of total billed charges,70% of total billed charges,629.91,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,671.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,642.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,377.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,587.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,503.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,587.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,403.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,755.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,131.61,1599,
NON-REFUNDABLE CANC. FEE,4141014,CDM,900,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,150,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,4141015,CDM,510,RC,95811,HCPCS,Outpatient,,,1996.73,1198.04,,3007.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1497.55,75,,,percent of total billed charges,75% of total billed charges,1528.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1597.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2973.05,350,,,Fee Schedule,350% of CMS OPPS Rate,866.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1527.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,898.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1397.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1198.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1397.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.71,100,,,Fee Schedule,100% of CMS OPPS Rate,958.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1797.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,312.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,312.89,3007.03,
HOME STUDY WITH TYPE II,4141016,CDM,920,RC,G0398,HCPCS,Outpatient,,,263.2,157.92,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.24,70,,,percent of total billed charges,70% of total billed charges,197.4,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,201.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,118.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,340,100,,,Case rate,Pays based on per visit ,184.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,126.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,236.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,468.02,
HOME STUDY WITH TYPE III,4141017,CDM,920,RC,G0399,HCPCS,Outpatient,,,263.2,157.92,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.24,70,,,percent of total billed charges,70% of total billed charges,197.4,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,201.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,118.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,340,100,,,Case rate,Pays based on per visit ,184.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,126.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,236.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,41.24,468.02,
EEG AWAKE/DROWSY,4141021,CDM,740,RC,95816,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
EEG AWAKE/ASLEEP,4141022,CDM,740,RC,95819,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
EEG CEREBRAL DEATH,4141023,CDM,740,RC,95824,HCPCS,Outpatient,,,1314,788.4,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,919.8,70,,,percent of total billed charges,70% of total billed charges,985.5,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1051.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,1005.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,226.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,591.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,919.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,919.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,630.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1182.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,205.9,1555.77,
EEG 24 HR SEIZURE MONITOR,4141030,CDM,740,RC,95951,HCPCS,Outpatient,,,4063.84,2438.3,,731.49,18,,,percent of total billed charges,pays at 18% of total charges,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,731.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2844.69,70,,,percent of total billed charges,70% of total billed charges,3047.88,75,,,percent of total billed charges,75% of total billed charges,2031.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3251.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2438.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3108.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,700.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1828.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2844.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2438.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,748,100,,,Case rate,Pays based on per visit ,2844.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4063.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3657.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,636.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.8,4063.84,
EEG DIGITAL,4141031,CDM,740,RC,95957,HCPCS,Outpatient,,,390.8,234.48,,70.34,18,,,percent of total billed charges,pays at 18% of total charges,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.56,70,,,percent of total billed charges,70% of total billed charges,293.1,75,,,percent of total billed charges,75% of total billed charges,195.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,312.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,234.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,298.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,273.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,234.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,748,100,,,Case rate,Pays based on per visit ,273.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,390.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,351.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.24,748,
EEG EXTENDED > 1 HR,4141032,CDM,740,RC,95813,HCPCS,Outpatient,,,901.8,541.08,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,631.26,70,,,percent of total billed charges,70% of total billed charges,676.35,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,721.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,689.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,405.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,631.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,541.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,631.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,432.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,811.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,141.31,901.29,
EEG SETUP,4141033,CDM,740,RC,95700,HCPCS,Outpatient,,,570.88,342.53,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,285.44,50,,,percent of total billed charges,pays at 50% of total billed charges,399.62,70,,,percent of total billed charges,70% of total billed charges,428.16,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,456.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,436.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,256.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,399.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,399.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,274.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,513.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,89.46,748,
EEG INTERMITTENT MONITORING 2-12 HOURS,4141034,CDM,740,RC,95706,HCPCS,Outpatient,,,570.88,342.53,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,285.44,50,,,percent of total billed charges,pays at 50% of total billed charges,399.62,70,,,percent of total billed charges,70% of total billed charges,428.16,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,456.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,436.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,256.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,399.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,342.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,399.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,274.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,513.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,89.46,901.29,
EEG INTERMITTENT MONITORING 12-26 HOURS,4141035,CDM,740,RC,95709,HCPCS,Outpatient,,,1095.3,657.18,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,547.65,50,,,percent of total billed charges,pays at 50% of total billed charges,766.71,70,,,percent of total billed charges,70% of total billed charges,821.48,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,876.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,837.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,188.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,492.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,766.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,657.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,766.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,525.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,985.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,171.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,171.63,1555.77,
VEEG 2- 12 HR INTMT MNTR,4141036,CDM,740,RC,95712,HCPCS,Outpatient,,,675,405,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,337.5,50,,,percent of total billed charges,pays at 50% of total billed charges,472.5,70,,,percent of total billed charges,70% of total billed charges,506.25,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,540,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,516.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,116.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,303.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,472.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,405,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,472.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,324,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,607.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,901.29,
VEEG 12-26 HR INTNT MNTR,4141037,CDM,740,RC,95715,HCPCS,Outpatient,,,1248,748.8,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,624,50,,,percent of total billed charges,pays at 50% of total billed charges,873.6,70,,,percent of total billed charges,70% of total billed charges,936,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,998.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,954.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,215.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,561.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,748.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,748,100,,,Case rate,Pays based on per visit ,873.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,599.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,195.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,195.56,1555.77,
"SLEEP STUDY, UNATTENDED",4141038,CDM,510,RC,G0399,HCPCS,Outpatient,,,900,540,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,688.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,405,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,432,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,810,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,810,
"SLEEP STUDY, UNATTENDED",4141039,CDM,510,RC,95800,HCPCS,Outpatient,,,900,540,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,720,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,688.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,405,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,540,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,432,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,810,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,810,
POLYSOMNOGRAPH W/MSLT,4141040,CDM,920,RC,95805,HCPCS,Outpatient,,,2799.36,1679.62,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1959.55,70,,,percent of total billed charges,70% of total billed charges,2099.52,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2239.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,2141.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1259.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1959.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1679.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,1959.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1343.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,2519.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,438.66,2519.42,
AUDITORY EP,4141503,CDM,471,RC,92585,HCPCS,Outpatient,,,663.3,397.98,,119.39,18,,,percent of total billed charges,pays at 18% of total charges,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,464.31,70,,,percent of total billed charges,70% of total billed charges,497.48,75,,,percent of total billed charges,75% of total billed charges,331.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,530.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,507.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,464.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,100,,,Case rate,Pays based on per visit ,464.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,663.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,596.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.94,663.3,
NERVE CONDUCTION STUDIES 3-4 STUDIES,4141507,CDM,922,RC,95908,HCPCS,Outpatient,,,280,168,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,901.29,
NERVE CONDUCTION STUDIES 1-2 STUDIES,4141600,CDM,922,RC,95907,HCPCS,Outpatient,,,280,168,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,498,
NERVE CONDUCTION STUDIES  5-6 STUDIES,4141602,CDM,922,RC,95909,HCPCS,Outpatient,,,280,168,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,901.29,
NERVE CONDUCTION STUDIES  7-8 STUDIES,4141603,CDM,922,RC,95910,HCPCS,Outpatient,,,280,168,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,901.29,
NERVE CONDUCTION STUDIES 9-10 STUDIES,4141604,CDM,922,RC,95911,HCPCS,Outpatient,,,280,168,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,280,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,1555.77,
NERVE CONDUCTION STUDIES 11-12 STUDIES,4141605,CDM,922,RC,95912,HCPCS,Outpatient,,,280,168,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,280,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,1555.77,
NERVE CONDUCTION STUDIES 13 OR MORE,4141606,CDM,922,RC,95913,HCPCS,Outpatient,,,280,168,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,280,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,498,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,1555.77,
POLYSOMNOGRAM < 6YRS,4141608,CDM,920,RC,95782,HCPCS,Outpatient,,,3421.44,2052.86,,3007.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2395.01,70,,,percent of total billed charges,70% of total billed charges,2566.08,75,,,percent of total billed charges,75% of total billed charges,1528.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2737.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2973.05,350,,,Fee Schedule,350% of CMS OPPS Rate,866.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2617.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,589.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1539.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2395.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2052.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,2395.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,3079.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,536.14,3079.3,
POLYSOMNOGRAPH  W/CPAP <6 YRS,4141609,CDM,920,RC,95783,HCPCS,Outpatient,,,3421.44,2052.86,,3007.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,849.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2395.01,70,,,percent of total billed charges,70% of total billed charges,2566.08,75,,,percent of total billed charges,75% of total billed charges,1528.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2737.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2973.05,350,,,Fee Schedule,350% of CMS OPPS Rate,866.42,103,,,Fee Schedule,103% of CMS OPPS Rate,2617.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,589.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1539.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2395.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2052.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1599,100,,,Case rate,Pays based on per visit ,2395.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,3079.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,536.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,849.44,100,,,Fee Schedule,100% of CMS OPPS Rate,536.14,3079.3,
GI LAB PRODUCTIVITY ONLY,4150001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
UGI W DILATION (ANY TYPE/ METHOD),4150002,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
KIT ENDOBRONCH 180 DEG TIP (NAV),4150005,CDM,272,RC,,,Outpatient,,,1632.88,979.73,,293.92,18,,,percent of total billed charges,pays at 18% of total charges,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,293.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,816.44,50,,,percent of total billed charges,pays at 50% of total billed charges,1143.02,70,,,percent of total billed charges,70% of total billed charges,1224.66,75,,,percent of total billed charges,75% of total billed charges,816.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1306.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,979.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1249.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1143.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,979.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1143.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1632.88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1469.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,255.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.87,1632.88,
DILATION OF ESOPHAGUS,4150006,CDM,750,RC,,,Outpatient,,,1954.48,1172.69,,351.81,18,,,percent of total billed charges,pays at 18% of total charges,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,977.24,50,,,percent of total billed charges,pays at 50% of total billed charges,1368.14,70,,,percent of total billed charges,70% of total billed charges,1465.86,75,,,percent of total billed charges,75% of total billed charges,977.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1563.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1495.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1368.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1172.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1954.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1759.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.27,1954.48,
ERCP W BALLOON SWEEP,4150008,CDM,750,RC,,,Outpatient,,,3004,1802.4,,540.72,18,,,percent of total billed charges,pays at 18% of total charges,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,540.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1502,50,,,percent of total billed charges,pays at 50% of total billed charges,2102.8,70,,,percent of total billed charges,70% of total billed charges,2253,75,,,percent of total billed charges,75% of total billed charges,1502,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1802.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2298.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1802.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1441.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3004,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2703.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.73,3004,
PATCHES PT EDGE (NAV),4150009,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
GI ANESTHESIA SERVICES,4150010,CDM,370,RC,,,Outpatient,,,450,270,,81,18,,,percent of total billed charges,pays at 18% of total charges,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,225,50,,,percent of total billed charges,pays at 50% of total billed charges,315,70,,,percent of total billed charges,70% of total billed charges,337.5,75,,,percent of total billed charges,75% of total billed charges,225,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,405,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.52,450,
FORCEPS BIOPSY (NAV),4150011,CDM,272,RC,,,Outpatient,,,144.5,86.7,,26.01,18,,,percent of total billed charges,pays at 18% of total charges,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.25,50,,,percent of total billed charges,pays at 50% of total billed charges,101.15,70,,,percent of total billed charges,70% of total billed charges,108.38,75,,,percent of total billed charges,75% of total billed charges,72.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,101.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,130.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.64,144.5,
BRUSH CYTOLOGY 10MM (NAV),4150016,CDM,272,RC,,,Outpatient,,,49,29.4,,8.82,18,,,percent of total billed charges,pays at 18% of total charges,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.5,50,,,percent of total billed charges,pays at 50% of total billed charges,34.3,70,,,percent of total billed charges,70% of total billed charges,36.75,75,,,percent of total billed charges,75% of total billed charges,24.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.68,49,
NEEDLE ARCPOINT PULM (NAV),4150017,CDM,272,RC,,,Outpatient,,,285,171,,51.3,18,,,percent of total billed charges,pays at 18% of total charges,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,50,,,percent of total billed charges,pays at 50% of total billed charges,199.5,70,,,percent of total billed charges,70% of total billed charges,213.75,75,,,percent of total billed charges,75% of total billed charges,142.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,285,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,256.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,285,
BRUSH CYTOLOGY TRIPLE (NAV),4150018,CDM,272,RC,,,Outpatient,,,210,126,,37.8,18,,,percent of total billed charges,pays at 18% of total charges,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105,50,,,percent of total billed charges,pays at 50% of total billed charges,147,70,,,percent of total billed charges,70% of total billed charges,157.5,75,,,percent of total billed charges,75% of total billed charges,105,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.91,210,
TOOL CORING (NAV),4150021,CDM,272,RC,,,Outpatient,,,478,286.8,,86.04,18,,,percent of total billed charges,pays at 18% of total charges,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239,50,,,percent of total billed charges,pays at 50% of total billed charges,334.6,70,,,percent of total billed charges,70% of total billed charges,358.5,75,,,percent of total billed charges,75% of total billed charges,239,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,382.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,286.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,365.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,334.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,286.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,478,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,430.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.9,478,
VISUALZTN PANCRTIC/COMN BILE DUCT PRODCT,4150023,CDM,750,RC,43273,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,657,
ERCP W ABLATION TMR/PLYP/LSN,4150027,CDM,750,RC,,,Outpatient,,,4190,2514,,754.2,18,,,percent of total billed charges,pays at 18% of total charges,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2095,50,,,percent of total billed charges,pays at 50% of total billed charges,2933,70,,,percent of total billed charges,70% of total billed charges,3142.5,75,,,percent of total billed charges,75% of total billed charges,2095,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2514,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3205.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1885.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2933,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2514,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1592.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2933,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4190,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3771,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.57,4190,
ERCP W STENT PLACEMENT,4150028,CDM,750,RC,,,Outpatient,,,3358.08,2014.85,,604.45,18,,,percent of total billed charges,pays at 18% of total charges,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,604.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1679.04,50,,,percent of total billed charges,pays at 50% of total billed charges,2350.66,70,,,percent of total billed charges,70% of total billed charges,2518.56,75,,,percent of total billed charges,75% of total billed charges,1679.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2686.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2014.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2568.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1511.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2350.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2014.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1276.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2350.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1611.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3358.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3022.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.21,3358.08,
ERCP W BALLOON DILATION,4150031,CDM,750,RC,,,Outpatient,,,3004,1802.4,,540.72,18,,,percent of total billed charges,pays at 18% of total charges,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,540.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1502,50,,,percent of total billed charges,pays at 50% of total billed charges,2102.8,70,,,percent of total billed charges,70% of total billed charges,2253,75,,,percent of total billed charges,75% of total billed charges,1502,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1802.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2298.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1802.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1141.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1441.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3004,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2703.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.73,3004,
ERCP W RMVL FB OR STENT,4150032,CDM,750,RC,,,Outpatient,,,4190,2514,,754.2,18,,,percent of total billed charges,pays at 18% of total charges,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,754.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2095,50,,,percent of total billed charges,pays at 50% of total billed charges,2933,70,,,percent of total billed charges,70% of total billed charges,3142.5,75,,,percent of total billed charges,75% of total billed charges,2095,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2514,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3205.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1885.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2933,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2514,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1592.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2933,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4190,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3771,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.57,4190,
BONE MARROW ASPIRATION,4150035,CDM,750,RC,,,Outpatient,,,630.3,378.18,,113.45,18,,,percent of total billed charges,pays at 18% of total charges,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.15,50,,,percent of total billed charges,pays at 50% of total billed charges,441.21,70,,,percent of total billed charges,70% of total billed charges,472.73,75,,,percent of total billed charges,75% of total billed charges,315.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,504.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,378.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,482.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,441.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,630.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,567.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.77,630.3,
ESOPH W BALLOON DILATION,4150036,CDM,750,RC,,,Outpatient,,,1954.48,1172.69,,351.81,18,,,percent of total billed charges,pays at 18% of total charges,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,977.24,50,,,percent of total billed charges,pays at 50% of total billed charges,1368.14,70,,,percent of total billed charges,70% of total billed charges,1465.86,75,,,percent of total billed charges,75% of total billed charges,977.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1563.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1495.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1368.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1172.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,742.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1368.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1954.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1759.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.27,1954.48,
ESOPH W BANDING,4150037,CDM,750,RC,,,Outpatient,,,1613.6,968.16,,290.45,18,,,percent of total billed charges,pays at 18% of total charges,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.8,50,,,percent of total billed charges,pays at 50% of total billed charges,1129.52,70,,,percent of total billed charges,70% of total billed charges,1210.2,75,,,percent of total billed charges,75% of total billed charges,806.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1290.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,968.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1234.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1129.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,968.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,613.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1129.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1613.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1452.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.85,1613.6,
ESOPH W CNTRL OF BLEED (HEMOSTASIS),4150038,CDM,750,RC,,,Outpatient,,,1954.48,1172.69,,351.81,18,,,percent of total billed charges,pays at 18% of total charges,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,977.24,50,,,percent of total billed charges,pays at 50% of total billed charges,1368.14,70,,,percent of total billed charges,70% of total billed charges,1465.86,75,,,percent of total billed charges,75% of total billed charges,977.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1563.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1495.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,879.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1368.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1172.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,742.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1368.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1954.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1759.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,306.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.27,1954.48,
BRUSH CYTOLOGY ASP PORT (NAV),4150041,CDM,272,RC,,,Outpatient,,,114.5,68.7,,20.61,18,,,percent of total billed charges,pays at 18% of total charges,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.25,50,,,percent of total billed charges,pays at 50% of total billed charges,80.15,70,,,percent of total billed charges,70% of total billed charges,85.88,75,,,percent of total billed charges,75% of total billed charges,57.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,91.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,68.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,114.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,114.5,
BRONCH W BRONCHIAL LAVAGE (BAL),4150042,CDM,750,RC,,,Outpatient,,,1902.24,1141.34,,342.4,18,,,percent of total billed charges,pays at 18% of total charges,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,951.12,50,,,percent of total billed charges,pays at 50% of total billed charges,1331.57,70,,,percent of total billed charges,70% of total billed charges,1426.68,75,,,percent of total billed charges,75% of total billed charges,951.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1521.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1455.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,856.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1331.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1141.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,722.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1331.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1902.24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1712.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.08,1902.24,
MARKER FIDUCIAL COIL (NAV),4150043,CDM,272,RC,,,Outpatient,,,288,172.8,,51.84,18,,,percent of total billed charges,pays at 18% of total charges,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,50,,,percent of total billed charges,pays at 50% of total billed charges,201.6,70,,,percent of total billed charges,70% of total billed charges,216,75,,,percent of total billed charges,75% of total billed charges,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,288,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,259.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.13,288,
KIT MARKER DELIVERY (NAV),4150044,CDM,272,RC,,,Outpatient,,,288,172.8,,51.84,18,,,percent of total billed charges,pays at 18% of total charges,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,50,,,percent of total billed charges,pays at 50% of total billed charges,201.6,70,,,percent of total billed charges,70% of total billed charges,216,75,,,percent of total billed charges,75% of total billed charges,144,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,230.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,220.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,172.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,201.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,288,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,259.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.13,288,
BRONCH W IMAGE-GUIDED NAV (ADD ON),4150046,CDM,750,RC,31627,HCPCS,Outpatient,,,1000,600,,180,18,,,percent of total billed charges,pays at 18% of total charges,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700,70,,,percent of total billed charges,70% of total billed charges,750,75,,,percent of total billed charges,75% of total billed charges,500,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,765,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,900,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.7,1000,
ABRAMS BIOPSY NEEDLE,4150050,CDM,272,RC,,,Outpatient,,,59,35.4,,10.62,18,,,percent of total billed charges,pays at 18% of total charges,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.5,50,,,percent of total billed charges,pays at 50% of total billed charges,41.3,70,,,percent of total billed charges,70% of total billed charges,44.25,75,,,percent of total billed charges,75% of total billed charges,29.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,59,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,53.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.25,59,
ESOPHAGOSCOPY W SUBMUCOSAL INJ,4150053,CDM,750,RC,43201,HCPCS,Outpatient,,,1613.6,968.16,,5604.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1613.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1949.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1129.52,70,,,percent of total billed charges,70% of total billed charges,1210.2,75,,,percent of total billed charges,75% of total billed charges,2849.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1290.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5541.47,350,,,Fee Schedule,350% of CMS OPPS Rate,1613.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1234.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,726.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1129.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,968.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1129.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3641.53,100,,,Fee Schedule,100% of CMS OPPS Rate,774.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1452.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1613.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,726.12,5604.8,
WANG BIOPSY NEEDLE,4150055,CDM,272,RC,,,Outpatient,,,274,164.4,,49.32,18,,,percent of total billed charges,pays at 18% of total charges,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,50,,,percent of total billed charges,pays at 50% of total billed charges,191.8,70,,,percent of total billed charges,70% of total billed charges,205.5,75,,,percent of total billed charges,75% of total billed charges,137,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,209.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,104.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,191.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,274,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.94,274,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",4150057,CDM,320,RC,76000,HCPCS,Outpatient,,,833.76,500.26,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,583.63,70,,,percent of total billed charges,70% of total billed charges,625.32,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,667.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,637.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,375.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,400.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,750.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,130.65,751.51,
"TRAY,PEG DISPOSABLE",4150058,CDM,272,RC,,,Outpatient,,,430.5,258.3,,77.49,18,,,percent of total billed charges,pays at 18% of total charges,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,215.25,50,,,percent of total billed charges,pays at 50% of total billed charges,301.35,70,,,percent of total billed charges,70% of total billed charges,322.88,75,,,percent of total billed charges,75% of total billed charges,215.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,344.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,329.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,301.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,430.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,387.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.46,430.5,
SPECIMEN SNARE,4150063,CDM,272,RC,,,Outpatient,,,104,62.4,,18.72,18,,,percent of total billed charges,pays at 18% of total charges,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52,50,,,percent of total billed charges,pays at 50% of total billed charges,72.8,70,,,percent of total billed charges,70% of total billed charges,78,75,,,percent of total billed charges,75% of total billed charges,52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,83.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,72.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,104,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,93.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,104,
SNARE SYSTEM,4150064,CDM,272,RC,,,Outpatient,,,132,79.2,,23.76,18,,,percent of total billed charges,pays at 18% of total charges,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66,50,,,percent of total billed charges,pays at 50% of total billed charges,92.4,70,,,percent of total billed charges,70% of total billed charges,99,75,,,percent of total billed charges,75% of total billed charges,66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,105.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,92.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,118.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.68,132,
UNIVERSAL FEEDING ADAPTER,4150071,CDM,272,RC,,,Outpatient,,,39,23.4,,7.02,18,,,percent of total billed charges,pays at 18% of total charges,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.5,50,,,percent of total billed charges,pays at 50% of total billed charges,27.3,70,,,percent of total billed charges,70% of total billed charges,29.25,75,,,percent of total billed charges,75% of total billed charges,19.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,31.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,27.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.11,39,
S V JEJUNA FEEDING TUBE,4150072,CDM,272,RC,,,Outpatient,,,200.5,120.3,,36.09,18,,,percent of total billed charges,pays at 18% of total charges,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100.25,50,,,percent of total billed charges,pays at 50% of total billed charges,140.35,70,,,percent of total billed charges,70% of total billed charges,150.38,75,,,percent of total billed charges,75% of total billed charges,100.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.42,200.5,
ESOPHAGEAL MOTILITY,4150080,CDM,750,RC,91010,HCPCS,Outpatient,,,1314,788.4,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,919.8,70,,,percent of total billed charges,70% of total billed charges,985.5,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1051.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,1005.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,226.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,591.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,919.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,919.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,630.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1182.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,205.9,1555.77,
DISPOSABLE PROBE FOR ERBE,4150091,CDM,272,RC,,,Outpatient,,,538.5,323.1,,96.93,18,,,percent of total billed charges,pays at 18% of total charges,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,269.25,50,,,percent of total billed charges,pays at 50% of total billed charges,376.95,70,,,percent of total billed charges,70% of total billed charges,403.88,75,,,percent of total billed charges,75% of total billed charges,269.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,430.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,376.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,323.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,376.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,538.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,484.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.38,538.5,
BALLOON DILATION BILIARY,4150093,CDM,272,RC,C1726,HCPCS,Outpatient,,,599.5,359.7,,107.91,18,,,percent of total billed charges,pays at 18% of total charges,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.65,70,,,percent of total billed charges,70% of total billed charges,449.63,75,,,percent of total billed charges,75% of total billed charges,299.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,479.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,359.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,458.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,419.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,359.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,227.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,419.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,599.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,539.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.94,599.5,
DILATOR BALLOON 3 STAGE,4150095,CDM,272,RC,C1726,HCPCS,Outpatient,,,538.5,323.1,,96.93,18,,,percent of total billed charges,pays at 18% of total charges,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.95,70,,,percent of total billed charges,70% of total billed charges,403.88,75,,,percent of total billed charges,75% of total billed charges,269.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,430.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,323.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,411.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,376.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,323.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204.63,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,376.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,538.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,484.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.38,538.5,
ENTEROSCOPY W/WO SPCMN CLCTN,4150100,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
ENTEROSCOPY W BIOPSY,4150101,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
ENTEROSCOPY W BLEED CNTRL,4150102,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
ENTEROSCOPY W RMVL TMR/PLYP/LSN,4150103,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
ENTEROSCOPY W ABLTN TMR/PLYP/LSN,4150104,CDM,750,RC,,,Outpatient,,,2672,1603.2,,480.96,18,,,percent of total billed charges,pays at 18% of total charges,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,480.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1336,50,,,percent of total billed charges,pays at 50% of total billed charges,1870.4,70,,,percent of total billed charges,70% of total billed charges,2004,75,,,percent of total billed charges,75% of total billed charges,1336,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1603.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2044.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1202.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1870.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1603.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1015.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1870.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1282.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2672,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2404.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,418.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.7,2672,
THORASCOPY WITH BX,4150105,CDM,750,RC,,,Outpatient,,,10902.42,6541.45,,1962.44,18,,,percent of total billed charges,pays at 18% of total charges,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1962.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5451.21,50,,,percent of total billed charges,pays at 50% of total billed charges,7631.69,70,,,percent of total billed charges,70% of total billed charges,8176.82,75,,,percent of total billed charges,75% of total billed charges,5451.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8721.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6541.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8340.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4906.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7631.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6541.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4142.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7631.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10902.42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9812.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1708.41,10902.42,
THORASCOPY W/OUT BX,4150106,CDM,750,RC,,,Outpatient,,,10902.42,6541.45,,1962.44,18,,,percent of total billed charges,pays at 18% of total charges,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1962.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5451.21,50,,,percent of total billed charges,pays at 50% of total billed charges,7631.69,70,,,percent of total billed charges,70% of total billed charges,8176.82,75,,,percent of total billed charges,75% of total billed charges,5451.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8721.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6541.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8340.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4906.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7631.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6541.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4142.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7631.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,10902.42,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,9812.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1708.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1708.41,10902.42,
TRACHEOSTOMY,4150107,CDM,750,RC,,,Outpatient,,,9392.5,5635.5,,1690.65,18,,,percent of total billed charges,pays at 18% of total charges,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1690.65,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4696.25,50,,,percent of total billed charges,pays at 50% of total billed charges,6574.75,70,,,percent of total billed charges,70% of total billed charges,7044.38,75,,,percent of total billed charges,75% of total billed charges,4696.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7514,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5635.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7185.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4226.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6574.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5635.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3569.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6574.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4508.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9392.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8453.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1471.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1471.8,9392.5,
EUS W/OUT BX,4150108,CDM,750,RC,,,Outpatient,,,3512.73,2107.64,,632.29,18,,,percent of total billed charges,pays at 18% of total charges,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1756.37,50,,,percent of total billed charges,pays at 50% of total billed charges,2458.91,70,,,percent of total billed charges,70% of total billed charges,2634.55,75,,,percent of total billed charges,75% of total billed charges,1756.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2810.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2107.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2687.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2458.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2107.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1334.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2458.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3512.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3161.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.44,3512.73,
EUS W/ ASPIRATION/ BX,4150109,CDM,750,RC,,,Outpatient,,,3512.73,2107.64,,632.29,18,,,percent of total billed charges,pays at 18% of total charges,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1756.37,50,,,percent of total billed charges,pays at 50% of total billed charges,2458.91,70,,,percent of total billed charges,70% of total billed charges,2634.55,75,,,percent of total billed charges,75% of total billed charges,1756.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2810.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2107.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2687.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2458.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2107.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1334.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2458.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3512.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3161.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.44,3512.73,
EUS W/ DRAIN OF PSEUDOCYST/ STENT,4150110,CDM,750,RC,,,Outpatient,,,6764.43,4058.66,,1217.6,18,,,percent of total billed charges,pays at 18% of total charges,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1217.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3382.22,50,,,percent of total billed charges,pays at 50% of total billed charges,4735.1,70,,,percent of total billed charges,70% of total billed charges,5073.32,75,,,percent of total billed charges,75% of total billed charges,3382.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5411.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4058.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5174.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3043.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4735.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4058.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2570.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4735.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3246.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6764.43,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6087.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1059.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.99,6764.43,
EUS W/ INJECTION,4150111,CDM,750,RC,,,Outpatient,,,3512.73,2107.64,,632.29,18,,,percent of total billed charges,pays at 18% of total charges,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1756.37,50,,,percent of total billed charges,pays at 50% of total billed charges,2458.91,70,,,percent of total billed charges,70% of total billed charges,2634.55,75,,,percent of total billed charges,75% of total billed charges,1756.37,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2810.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2107.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2687.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1580.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2458.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2107.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1334.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2458.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3512.73,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3161.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,550.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.44,3512.73,
SHARKCORE NEEDLE,4150112,CDM,272,RC,,,Outpatient,,,1699.1,1019.46,,305.84,18,,,percent of total billed charges,pays at 18% of total charges,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,305.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,849.55,50,,,percent of total billed charges,pays at 50% of total billed charges,1189.37,70,,,percent of total billed charges,70% of total billed charges,1274.33,75,,,percent of total billed charges,75% of total billed charges,849.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1359.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1019.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1299.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1189.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1019.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,645.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1189.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,815.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1699.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1529.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.25,1699.1,
SHARKCORE BIO SYSTEM,4150113,CDM,272,RC,,,Outpatient,,,488.8,293.28,,87.98,18,,,percent of total billed charges,pays at 18% of total charges,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.4,50,,,percent of total billed charges,pays at 50% of total billed charges,342.16,70,,,percent of total billed charges,70% of total billed charges,366.6,75,,,percent of total billed charges,75% of total billed charges,244.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,391.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,373.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,342.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,293.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,185.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,342.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,488.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,439.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.59,488.8,
SHARKCORE LG FINE NDL BX,4150114,CDM,272,RC,,,Outpatient,,,781.3,468.78,,140.63,18,,,percent of total billed charges,pays at 18% of total charges,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,140.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,390.65,50,,,percent of total billed charges,pays at 50% of total billed charges,546.91,70,,,percent of total billed charges,70% of total billed charges,585.98,75,,,percent of total billed charges,75% of total billed charges,390.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,625.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,468.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,597.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,546.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,468.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,546.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,781.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,703.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,122.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.43,781.3,
ENDOPATH TROCAR,4150115,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
ECHOTIP ULTRA,4150116,CDM,272,RC,,,Outpatient,,,429,257.4,,77.22,18,,,percent of total billed charges,pays at 18% of total charges,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,214.5,50,,,percent of total billed charges,pays at 50% of total billed charges,300.3,70,,,percent of total billed charges,70% of total billed charges,321.75,75,,,percent of total billed charges,75% of total billed charges,214.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,343.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,328.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,300.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,257.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,300.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,429,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,386.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.22,429,
RAPID REFILL INJECTION SYSTEM,4150117,CDM,272,RC,,,Outpatient,,,315,189,,56.7,18,,,percent of total billed charges,pays at 18% of total charges,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,157.5,50,,,percent of total billed charges,pays at 50% of total billed charges,220.5,70,,,percent of total billed charges,70% of total billed charges,236.25,75,,,percent of total billed charges,75% of total billed charges,157.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,252,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,189,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,119.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,220.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,315,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,283.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.36,315,
PANCREATIC STENT KIT,4150118,CDM,278,RC,C1874,HCPCS,Outpatient,,,253.5,152.1,,45.63,18,,,percent of total billed charges,pays at 18% of total charges,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.45,70,,,percent of total billed charges,70% of total billed charges,190.13,75,,,percent of total billed charges,75% of total billed charges,126.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,202.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,152.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,253.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,177.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,152.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,177.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,253.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,253.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.72,253.5,
SIGMOIDOSCOPY W EUS W/OUT BX,4150119,CDM,750,RC,,,Outpatient,,,1796.75,1078.05,,323.42,18,,,percent of total billed charges,pays at 18% of total charges,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,323.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,898.38,50,,,percent of total billed charges,pays at 50% of total billed charges,1257.73,70,,,percent of total billed charges,70% of total billed charges,1347.56,75,,,percent of total billed charges,75% of total billed charges,898.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1437.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1078.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1374.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1257.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1078.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,682.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1257.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,862.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1796.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1617.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.55,1796.75,
SIGMOIDOSCOPY W EUS W BX,4150120,CDM,750,RC,,,Outpatient,,,2347.57,1408.54,,422.56,18,,,percent of total billed charges,pays at 18% of total charges,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,422.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1173.79,50,,,percent of total billed charges,pays at 50% of total billed charges,1643.3,70,,,percent of total billed charges,70% of total billed charges,1760.68,75,,,percent of total billed charges,75% of total billed charges,1173.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1878.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1408.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1795.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1056.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1643.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1643.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2347.57,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2112.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.86,2347.57,
COLONOSCOPY W EUS W/OUT BX,4150121,CDM,750,RC,,,Outpatient,,,2347.57,1408.54,,422.56,18,,,percent of total billed charges,pays at 18% of total charges,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,422.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1173.79,50,,,percent of total billed charges,pays at 50% of total billed charges,1643.3,70,,,percent of total billed charges,70% of total billed charges,1760.68,75,,,percent of total billed charges,75% of total billed charges,1173.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1878.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1408.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1795.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1056.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1643.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1643.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2347.57,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2112.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.86,2347.57,
COLONOSCOPY W EUS W BX,4150122,CDM,750,RC,,,Outpatient,,,2347.57,1408.54,,422.56,18,,,percent of total billed charges,pays at 18% of total charges,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,422.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1173.79,50,,,percent of total billed charges,pays at 50% of total billed charges,1643.3,70,,,percent of total billed charges,70% of total billed charges,1760.68,75,,,percent of total billed charges,75% of total billed charges,1173.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1878.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1408.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1795.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1056.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1643.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,892.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1643.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2347.57,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2112.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.86,2347.57,
J TUBE INSERTION,4150994,CDM,750,RC,,,Outpatient,,,496.8,298.08,,89.42,18,,,percent of total billed charges,pays at 18% of total charges,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.4,50,,,percent of total billed charges,pays at 50% of total billed charges,347.76,70,,,percent of total billed charges,70% of total billed charges,372.6,75,,,percent of total billed charges,75% of total billed charges,248.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,397.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,347.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,496.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,447.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.85,496.8,
UGI DIAGN W/WO SPCMN CLCTN,4151000,CDM,750,RC,,,Outpatient,,,3305.61,1983.37,,595.01,18,,,percent of total billed charges,pays at 18% of total charges,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,595.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1652.81,50,,,percent of total billed charges,pays at 50% of total billed charges,2313.93,70,,,percent of total billed charges,70% of total billed charges,2479.21,75,,,percent of total billed charges,75% of total billed charges,1652.81,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2644.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1983.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2528.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1487.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2313.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1983.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1256.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2313.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1586.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3305.61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2975.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.99,3305.61,
COLONOSCOPY DIAGN W/WO SPCMN CLCTN,4151001,CDM,750,RC,,,Outpatient,,,4092.22,2455.33,,736.6,18,,,percent of total billed charges,pays at 18% of total charges,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,736.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2046.11,50,,,percent of total billed charges,pays at 50% of total billed charges,2864.55,70,,,percent of total billed charges,70% of total billed charges,3069.17,75,,,percent of total billed charges,75% of total billed charges,2046.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3273.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2455.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3130.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1841.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2864.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2455.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1555.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2864.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1964.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4092.22,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3683,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,641.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.25,4092.22,
COLONOSCOPY W RMVL TMR/PLYP/LSN,4151002,CDM,750,RC,,,Outpatient,,,5333.68,3200.21,,960.06,18,,,percent of total billed charges,pays at 18% of total charges,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,960.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2666.84,50,,,percent of total billed charges,pays at 50% of total billed charges,3733.58,70,,,percent of total billed charges,70% of total billed charges,4000.26,75,,,percent of total billed charges,75% of total billed charges,2666.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4266.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3200.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4080.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2400.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3733.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3200.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2026.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3733.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2560.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5333.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4800.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,835.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.79,5333.68,
BRONCH W WSHNGS AND/OR BRSHNG,4151003,CDM,750,RC,,,Outpatient,,,2983.32,1789.99,,537,18,,,percent of total billed charges,pays at 18% of total charges,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,537,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1491.66,50,,,percent of total billed charges,pays at 50% of total billed charges,2088.32,70,,,percent of total billed charges,70% of total billed charges,2237.49,75,,,percent of total billed charges,75% of total billed charges,1491.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2386.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1789.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2282.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1342.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2088.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1789.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1133.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2088.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2983.32,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2684.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,467.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.49,2983.32,
TRACHEOBRONCHOSCOPY THRU OSTOMY,4151004,CDM,750,RC,31615,HCPCS,Outpatient,,,1181.48,708.89,,1470.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1181.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,415.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,415.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,937.63,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,827.04,70,,,percent of total billed charges,70% of total billed charges,886.11,75,,,percent of total billed charges,75% of total billed charges,747.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,945.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1453.53,350,,,Fee Schedule,350% of CMS OPPS Rate,423.59,103,,,Fee Schedule,103% of CMS OPPS Rate,903.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,531.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,827.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,708.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,827.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,955.17,100,,,Fee Schedule,100% of CMS OPPS Rate,567.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,1470.14,
SIGMOIDOSCOPY W/WO SPCMN CLCTN,4151005,CDM,750,RC,,,Outpatient,,,2012.56,1207.54,,362.26,18,,,percent of total billed charges,pays at 18% of total charges,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,362.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1006.28,50,,,percent of total billed charges,pays at 50% of total billed charges,1408.79,70,,,percent of total billed charges,70% of total billed charges,1509.42,75,,,percent of total billed charges,75% of total billed charges,1006.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1610.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1207.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1539.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1408.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1207.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,764.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1408.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2012.56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1811.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,315.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.37,2012.56,
UGI W BIOPSY,4151006,CDM,750,RC,,,Outpatient,,,4602.75,2761.65,,828.5,18,,,percent of total billed charges,pays at 18% of total charges,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,828.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2301.38,50,,,percent of total billed charges,pays at 50% of total billed charges,3221.93,70,,,percent of total billed charges,70% of total billed charges,3452.06,75,,,percent of total billed charges,75% of total billed charges,2301.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3682.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2761.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3521.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2071.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3221.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2761.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1749.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3221.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2209.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4602.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4142.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,721.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.25,4602.75,
COLONOSCOPY WITH BIOPSY,4151007,CDM,750,RC,,,Outpatient,,,4477,2686.2,,805.86,18,,,percent of total billed charges,pays at 18% of total charges,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2238.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3133.9,70,,,percent of total billed charges,70% of total billed charges,3357.75,75,,,percent of total billed charges,75% of total billed charges,2238.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3581.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2686.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3424.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2014.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3133.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2686.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1701.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3133.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2148.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4477,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4029.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,701.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.55,4477,
BRONCH W BIOPSY(S),4151008,CDM,750,RC,,,Outpatient,,,4557.85,2734.71,,820.41,18,,,percent of total billed charges,pays at 18% of total charges,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,820.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2278.93,50,,,percent of total billed charges,pays at 50% of total billed charges,3190.5,70,,,percent of total billed charges,70% of total billed charges,3418.39,75,,,percent of total billed charges,75% of total billed charges,2278.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3646.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2734.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3486.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2051.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3190.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2734.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1731.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3190.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4557.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4102.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,714.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.22,4557.85,
SIGMOID W BIOPSY(S),4151009,CDM,750,RC,,,Outpatient,,,2438.48,1463.09,,438.93,18,,,percent of total billed charges,pays at 18% of total charges,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.93,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1219.24,50,,,percent of total billed charges,pays at 50% of total billed charges,1706.94,70,,,percent of total billed charges,70% of total billed charges,1828.86,75,,,percent of total billed charges,75% of total billed charges,1219.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1950.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1463.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1865.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1097.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1706.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1463.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,926.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1706.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1170.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2438.48,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2194.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,382.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.11,2438.48,
ERCP DIAG W/WO SPCMN CLCTN,4151010,CDM,750,RC,,,Outpatient,,,3004,1802.4,,540.72,18,,,percent of total billed charges,pays at 18% of total charges,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,540.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1502,50,,,percent of total billed charges,pays at 50% of total billed charges,2102.8,70,,,percent of total billed charges,70% of total billed charges,2253,75,,,percent of total billed charges,75% of total billed charges,1502,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1802.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2298.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1802.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1141.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1441.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3004,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2703.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,470.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.73,3004,
SIGMOIDOSCOPY W RMVL TMR/PLPY/LSN,4151012,CDM,750,RC,,,Outpatient,,,2088,1252.8,,375.84,18,,,percent of total billed charges,pays at 18% of total charges,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1044,50,,,percent of total billed charges,pays at 50% of total billed charges,1461.6,70,,,percent of total billed charges,70% of total billed charges,1566,75,,,percent of total billed charges,75% of total billed charges,1044,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1252.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1597.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1252.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,793.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2088,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1879.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.19,2088,
UGI W SUBMUCOSAL INJECTION,4151014,CDM,750,RC,43236,HCPCS,Outpatient,,,2679.2,1607.52,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2679.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1875.44,70,,,percent of total billed charges,70% of total billed charges,2009.4,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2143.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,2049.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1875.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1607.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1875.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1286.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2411.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2679.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,2679.2,
UGI W RMVL FB,4151015,CDM,750,RC,,,Outpatient,,,3291.2,1974.72,,592.42,18,,,percent of total billed charges,pays at 18% of total charges,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1645.6,50,,,percent of total billed charges,pays at 50% of total billed charges,2303.84,70,,,percent of total billed charges,70% of total billed charges,2468.4,75,,,percent of total billed charges,75% of total billed charges,1645.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2632.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1974.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2517.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1481.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2303.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1974.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1250.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2303.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1579.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3291.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2962.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.73,3291.2,
COLONOSCOPY W RMVL FB,4151016,CDM,750,RC,,,Outpatient,,,2850,1710,,513,18,,,percent of total billed charges,pays at 18% of total charges,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,513,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1425,50,,,percent of total billed charges,pays at 50% of total billed charges,1995,70,,,percent of total billed charges,70% of total billed charges,2137.5,75,,,percent of total billed charges,75% of total billed charges,1425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1710,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2180.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1282.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1995,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1710,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1083,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1995,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2565,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,446.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.6,2850,
SIGMOIDOSCOPY W RMVL FB,4151017,CDM,750,RC,,,Outpatient,,,2088,1252.8,,375.84,18,,,percent of total billed charges,pays at 18% of total charges,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1044,50,,,percent of total billed charges,pays at 50% of total billed charges,1461.6,70,,,percent of total billed charges,70% of total billed charges,1566,75,,,percent of total billed charges,75% of total billed charges,1044,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1252.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1597.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1252.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,793.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2088,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1879.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.19,2088,
ERCP W BIOPSY(S),4151019,CDM,750,RC,,,Outpatient,,,3080,1848,,554.4,18,,,percent of total billed charges,pays at 18% of total charges,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,554.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1540,50,,,percent of total billed charges,pays at 50% of total billed charges,2156,70,,,percent of total billed charges,70% of total billed charges,2310,75,,,percent of total billed charges,75% of total billed charges,1540,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2356.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1848,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1478.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2772,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.64,3080,
THORACENTESIS WITHOUT IMAGE,4151020,CDM,750,RC,32554,HCPCS,Outpatient,,,1077.48,646.49,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1077.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,754.24,70,,,percent of total billed charges,70% of total billed charges,808.11,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,861.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,824.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,754.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,646.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,754.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,517.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,969.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1077.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,484.87,1861.73,
NEEDLE TRANSBRONCHIAL,4151021,CDM,272,RC,,,Outpatient,,,301.05,180.63,,54.19,18,,,percent of total billed charges,pays at 18% of total charges,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.53,50,,,percent of total billed charges,pays at 50% of total billed charges,210.74,70,,,percent of total billed charges,70% of total billed charges,225.79,75,,,percent of total billed charges,75% of total billed charges,150.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,210.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,301.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.17,301.05,
UGI W ABLTN TMR/PLYP/LSN,4151022,CDM,750,RC,,,Outpatient,,,3291.2,1974.72,,592.42,18,,,percent of total billed charges,pays at 18% of total charges,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,592.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1645.6,50,,,percent of total billed charges,pays at 50% of total billed charges,2303.84,70,,,percent of total billed charges,70% of total billed charges,2468.4,75,,,percent of total billed charges,75% of total billed charges,1645.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2632.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1974.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2517.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1481.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2303.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1974.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1250.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2303.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1579.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3291.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2962.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.73,3291.2,
TUNNELED INDWELLING CATH INSERTION,4151023,CDM,750,RC,32550,HCPCS,Outpatient,,,8416,5049.6,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5579.43,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5891.2,70,,,percent of total billed charges,70% of total billed charges,6312,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,6438.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1450.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3787.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5891.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5049.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5891.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4039.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7574.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.79,11398.68,
EGD W RMVL TMR/PLYP/LSN,4151024,CDM,750,RC,,,Outpatient,,,3287.68,1972.61,,591.78,18,,,percent of total billed charges,pays at 18% of total charges,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,591.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1643.84,50,,,percent of total billed charges,pays at 50% of total billed charges,2301.38,70,,,percent of total billed charges,70% of total billed charges,2465.76,75,,,percent of total billed charges,75% of total billed charges,1643.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2630.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1972.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2515.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1479.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2301.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1972.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1249.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2301.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1578.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3287.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2958.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,515.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.18,3287.68,
TUNNELED INDWELLING CATH REMOVAL,4151025,CDM,750,RC,32552,HCPCS,Outpatient,,,1707,1024.2,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1194.9,70,,,percent of total billed charges,70% of total billed charges,1280.25,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1365.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.43,103,,,Fee Schedule,103% of CMS OPPS Rate,1305.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,768.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,100,,,Fee Schedule,100% of CMS OPPS Rate,819.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,267.49,1861.73,
THORACENTESIS WITH IMAGE,4151026,CDM,750,RC,32555,HCPCS,Outpatient,,,1707,1024.2,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1707,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1194.9,70,,,percent of total billed charges,70% of total billed charges,1280.25,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1365.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,1305.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,768.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1024.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1194.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,819.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1707,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
"Flexible, fiberoptic diagnostic laryngoscopy",4151027,CDM,750,RC,31575,HCPCS,Outpatient,,,260.8,156.48,,575.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,260.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,162.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,162.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,320.27,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,182.56,70,,,percent of total billed charges,70% of total billed charges,195.6,75,,,percent of total billed charges,75% of total billed charges,292.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.75,350,,,Fee Schedule,350% of CMS OPPS Rate,165.74,103,,,Fee Schedule,103% of CMS OPPS Rate,199.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,117.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,182.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,373.74,100,,,Fee Schedule,100% of CMS OPPS Rate,125.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,234.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,117.36,657,
RECTAL DILATION,4151029,CDM,750,RC,,,Outpatient,,,2632.8,1579.68,,473.9,18,,,percent of total billed charges,pays at 18% of total charges,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,473.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1316.4,50,,,percent of total billed charges,pays at 50% of total billed charges,1842.96,70,,,percent of total billed charges,70% of total billed charges,1974.6,75,,,percent of total billed charges,75% of total billed charges,1316.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2106.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1579.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2014.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1184.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1842.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1579.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1000.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1842.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1263.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2632.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2369.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,412.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.56,2632.8,
COLONOSCOPY W DILATION,4151034,CDM,750,RC,,,Outpatient,,,2610,1566,,469.8,18,,,percent of total billed charges,pays at 18% of total charges,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1305,50,,,percent of total billed charges,pays at 50% of total billed charges,1827,70,,,percent of total billed charges,70% of total billed charges,1957.5,75,,,percent of total billed charges,75% of total billed charges,1305,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1566,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1996.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1827,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1566,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,991.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1827,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2610,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2349,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.99,2610,
COLONOSCOPY W SUBMUCOSAL INJ,4151037,CDM,750,RC,,,Outpatient,,,1597,958.2,,287.46,18,,,percent of total billed charges,pays at 18% of total charges,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,798.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1117.9,70,,,percent of total billed charges,70% of total billed charges,1197.75,75,,,percent of total billed charges,75% of total billed charges,798.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,958.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1221.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,718.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1117.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,958.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,606.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1117.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1597,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1437.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,250.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.25,1597,
COLONOSCOPY W BLEED CNTRL,4151039,CDM,750,RC,,,Outpatient,,,4222.68,2533.61,,760.08,18,,,percent of total billed charges,pays at 18% of total charges,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,760.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2111.34,50,,,percent of total billed charges,pays at 50% of total billed charges,2955.88,70,,,percent of total billed charges,70% of total billed charges,3167.01,75,,,percent of total billed charges,75% of total billed charges,2111.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3378.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2533.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3230.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1900.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2955.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2533.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1604.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2955.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2026.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4222.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3800.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,661.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.69,4222.68,
BILIARY RETRIEVAL BALLOON,4151040,CDM,272,RC,,,Outpatient,,,384.5,230.7,,69.21,18,,,percent of total billed charges,pays at 18% of total charges,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.25,50,,,percent of total billed charges,pays at 50% of total billed charges,269.15,70,,,percent of total billed charges,70% of total billed charges,288.38,75,,,percent of total billed charges,75% of total billed charges,192.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,269.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,269.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,384.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,346.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.25,384.5,
METAL BILARY STENT,4151041,CDM,278,RC,C1876,HCPCS,Outpatient,,,1563.5,938.1,,281.43,18,,,percent of total billed charges,pays at 18% of total charges,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,281.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1094.45,70,,,percent of total billed charges,70% of total billed charges,1172.63,75,,,percent of total billed charges,75% of total billed charges,781.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1250.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,938.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1563.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,269.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1094.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,938.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,594.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1094.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1563.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1563.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,245,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245,1563.5,
"TRAY, THORACENTESIS (G)",4151049,CDM,272,RC,,,Outpatient,,,159.5,95.7,,28.71,18,,,percent of total billed charges,pays at 18% of total charges,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.75,50,,,percent of total billed charges,pays at 50% of total billed charges,111.65,70,,,percent of total billed charges,70% of total billed charges,119.63,75,,,percent of total billed charges,75% of total billed charges,79.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,159.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,143.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,159.5,
"NEEDLE, ARTICULATED INJECTION",4151050,CDM,272,RC,,,Outpatient,,,193,115.8,,34.74,18,,,percent of total billed charges,pays at 18% of total charges,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.5,50,,,percent of total billed charges,pays at 50% of total billed charges,135.1,70,,,percent of total billed charges,70% of total billed charges,144.75,75,,,percent of total billed charges,75% of total billed charges,96.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,135.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,173.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,193,
FORCEPS/BASKET RETRIEVER,4151068,CDM,272,RC,,,Outpatient,,,408,244.8,,73.44,18,,,percent of total billed charges,pays at 18% of total charges,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,204,50,,,percent of total billed charges,pays at 50% of total billed charges,285.6,70,,,percent of total billed charges,70% of total billed charges,306,75,,,percent of total billed charges,75% of total billed charges,204,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,326.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,244.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,312.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,285.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,244.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,285.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,408,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,367.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.93,408,
KIT GASTRO PEG REPL,4151070,CDM,272,RC,,,Outpatient,,,98,58.8,,17.64,18,,,percent of total billed charges,pays at 18% of total charges,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49,50,,,percent of total billed charges,pays at 50% of total billed charges,68.6,70,,,percent of total billed charges,70% of total billed charges,73.5,75,,,percent of total billed charges,75% of total billed charges,49,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,78.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,68.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,88.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.36,98,
BALLOON- STONE EXTRACTOR,4151072,CDM,272,RC,,,Outpatient,,,313,187.8,,56.34,18,,,percent of total billed charges,pays at 18% of total charges,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,56.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.5,50,,,percent of total billed charges,pays at 50% of total billed charges,219.1,70,,,percent of total billed charges,70% of total billed charges,234.75,75,,,percent of total billed charges,75% of total billed charges,156.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,250.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,187.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,219.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,118.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,219.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,313,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,281.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.05,313,
OMNITOME SPHINCERTOME,4151075,CDM,272,RC,,,Outpatient,,,513,307.8,,92.34,18,,,percent of total billed charges,pays at 18% of total charges,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,256.5,50,,,percent of total billed charges,pays at 50% of total billed charges,359.1,70,,,percent of total billed charges,70% of total billed charges,384.75,75,,,percent of total billed charges,75% of total billed charges,256.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,410.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,307.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,392.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,359.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,307.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,359.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,513,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,461.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.39,513,
SYSTEM STENT INTROD OASIS,4151077,CDM,278,RC,C1876,HCPCS,Outpatient,,,379,227.4,,68.22,18,,,percent of total billed charges,pays at 18% of total charges,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.3,70,,,percent of total billed charges,70% of total billed charges,284.25,75,,,percent of total billed charges,75% of total billed charges,189.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,303.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,227.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,379,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,65.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,265.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,265.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,379,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,379,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.39,379,
BILIARY STENT,4151079,CDM,278,RC,C2625,HCPCS,Outpatient,,,1986.5,1191.9,,357.57,18,,,percent of total billed charges,pays at 18% of total charges,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,357.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.55,70,,,percent of total billed charges,70% of total billed charges,1489.88,75,,,percent of total billed charges,75% of total billed charges,993.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1589.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1191.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1986.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,342.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1390.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1191.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,754.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1390.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1986.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1986.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,311.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.28,1986.5,
SIGMOIDOSCOPY FLEX W BAND LIGATION,4151080,CDM,750,RC,,,Outpatient,,,2610,1566,,469.8,18,,,percent of total billed charges,pays at 18% of total charges,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,469.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1305,50,,,percent of total billed charges,pays at 50% of total billed charges,1827,70,,,percent of total billed charges,70% of total billed charges,1957.5,75,,,percent of total billed charges,75% of total billed charges,1305,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2088,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1566,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1996.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1827,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1566,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,991.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1827,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2610,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2349,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,408.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.99,2610,
SIGMOIDOSCOPY W BLEED CNTRL,4151086,CDM,750,RC,,,Outpatient,,,2088,1252.8,,375.84,18,,,percent of total billed charges,pays at 18% of total charges,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,375.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1044,50,,,percent of total billed charges,pays at 50% of total billed charges,1461.6,70,,,percent of total billed charges,70% of total billed charges,1566,75,,,percent of total billed charges,75% of total billed charges,1044,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1252.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1597.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1252.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,793.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1461.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2088,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1879.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.19,2088,
UGI W BLEED CNTRL,4151087,CDM,750,RC,,,Outpatient,,,2925.72,1755.43,,526.63,18,,,percent of total billed charges,pays at 18% of total charges,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,526.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1462.86,50,,,percent of total billed charges,pays at 50% of total billed charges,2048,70,,,percent of total billed charges,70% of total billed charges,2194.29,75,,,percent of total billed charges,75% of total billed charges,1462.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2340.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1755.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2238.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1316.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2048,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1755.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1111.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2048,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1404.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2925.72,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2633.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.46,2925.72,
ESOPH W DILATION,4151088,CDM,750,RC,,,Outpatient,,,1613.6,968.16,,290.45,18,,,percent of total billed charges,pays at 18% of total charges,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,290.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,806.8,50,,,percent of total billed charges,pays at 50% of total billed charges,1129.52,70,,,percent of total billed charges,70% of total billed charges,1210.2,75,,,percent of total billed charges,75% of total billed charges,806.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1290.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,968.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1234.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1129.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,968.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,613.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1129.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1613.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1452.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,252.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.85,1613.6,
HEMORRHOIDECTOMY,4151089,CDM,750,RC,,,Outpatient,,,737.6,442.56,,132.77,18,,,percent of total billed charges,pays at 18% of total charges,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.77,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.8,50,,,percent of total billed charges,pays at 50% of total billed charges,516.32,70,,,percent of total billed charges,70% of total billed charges,553.2,75,,,percent of total billed charges,75% of total billed charges,368.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,590.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,564.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,516.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,442.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,280.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,516.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,737.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,663.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.58,737.6,
HEMOSPRAY #7,4151091,CDM,272,RC,,,Outpatient,,,1905,1143,,342.9,18,,,percent of total billed charges,pays at 18% of total charges,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,952.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1333.5,70,,,percent of total billed charges,70% of total billed charges,1428.75,75,,,percent of total billed charges,75% of total billed charges,952.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1524,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1143,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1457.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1333.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1333.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,914.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1905,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1714.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.51,1905,
HEMOSPRAY #10,4151092,CDM,272,RC,,,Outpatient,,,1905,1143,,342.9,18,,,percent of total billed charges,pays at 18% of total charges,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,342.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,952.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1333.5,70,,,percent of total billed charges,70% of total billed charges,1428.75,75,,,percent of total billed charges,75% of total billed charges,952.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1524,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1143,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1457.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1333.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,723.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1333.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,914.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1905,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1714.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.51,1905,
BRONCHOSCOPY W EBUS,4151652,CDM,750,RC,,,Outpatient,,,4361,2616.6,,784.98,18,,,percent of total billed charges,pays at 18% of total charges,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,784.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2180.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3052.7,70,,,percent of total billed charges,70% of total billed charges,3270.75,75,,,percent of total billed charges,75% of total billed charges,2180.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3488.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2616.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3336.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1962.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3052.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2616.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1657.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3052.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2093.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4361,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3924.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,683.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.37,4361,
UGI W GASTRO TUBE PLCMNT,4152001,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
TUBE THORACOSTOMY,4152002,CDM,750,RC,,,Outpatient,,,1344.24,806.54,,241.96,18,,,percent of total billed charges,pays at 18% of total charges,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,672.12,50,,,percent of total billed charges,pays at 50% of total billed charges,940.97,70,,,percent of total billed charges,70% of total billed charges,1008.18,75,,,percent of total billed charges,75% of total billed charges,672.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1075.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,806.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1028.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,940.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,806.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,510.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,940.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1344.24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1209.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.64,1344.24,
BRONCH W RMVL FB,4152003,CDM,750,RC,,,Outpatient,,,3314.8,1988.88,,596.66,18,,,percent of total billed charges,pays at 18% of total charges,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,596.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1657.4,50,,,percent of total billed charges,pays at 50% of total billed charges,2320.36,70,,,percent of total billed charges,70% of total billed charges,2486.1,75,,,percent of total billed charges,75% of total billed charges,1657.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2651.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1988.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2535.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1491.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2320.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1988.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1259.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2320.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1591.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3314.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2983.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,519.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.43,3314.8,
EGD W STENT PLCMNT,4152004,CDM,750,RC,,,Outpatient,,,5139,3083.4,,925.02,18,,,percent of total billed charges,pays at 18% of total charges,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,925.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2569.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3597.3,70,,,percent of total billed charges,70% of total billed charges,3854.25,75,,,percent of total billed charges,75% of total billed charges,2569.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3083.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3931.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2312.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3597.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3083.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1952.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3597.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2466.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5139,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4625.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,805.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.28,5139,
EGD W INSERTION OF TUBE OR CATH,4152006,CDM,750,RC,,,Outpatient,,,1453,871.8,,261.54,18,,,percent of total billed charges,pays at 18% of total charges,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,726.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1017.1,70,,,percent of total billed charges,70% of total billed charges,1089.75,75,,,percent of total billed charges,75% of total billed charges,726.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1162.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,871.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1111.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1017.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,871.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,552.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1017.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1453,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1307.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.69,1453,
TRACHEOTOMY TUBE CHANGE ESTBLSH,4152007,CDM,750,RC,,,Outpatient,,,293.45,176.07,,52.82,18,,,percent of total billed charges,pays at 18% of total charges,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.73,50,,,percent of total billed charges,pays at 50% of total billed charges,205.42,70,,,percent of total billed charges,70% of total billed charges,220.09,75,,,percent of total billed charges,75% of total billed charges,146.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,234.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,176.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,205.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,293.45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,264.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.98,293.45,
GASTROSTOMY TUBE CHNG PERCTN,4152008,CDM,750,RC,,,Outpatient,,,496.8,298.08,,89.42,18,,,percent of total billed charges,pays at 18% of total charges,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.4,50,,,percent of total billed charges,pays at 50% of total billed charges,347.76,70,,,percent of total billed charges,70% of total billed charges,372.6,75,,,percent of total billed charges,75% of total billed charges,248.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,397.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,298.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,380.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,347.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,496.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,447.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.85,496.8,
ERCP W SPHINCTER/PAPILLOT,4152010,CDM,750,RC,,,Outpatient,,,3080,1848,,554.4,18,,,percent of total billed charges,pays at 18% of total charges,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,554.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1540,50,,,percent of total billed charges,pays at 50% of total billed charges,2156,70,,,percent of total billed charges,70% of total billed charges,2310,75,,,percent of total billed charges,75% of total billed charges,1540,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2464,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2356.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1386,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1848,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1170.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2156,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1478.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3080,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2772,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,482.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.64,3080,
RADIAL JAW 3 FORCEP,4152013,CDM,272,RC,,,Outpatient,,,216.5,129.9,,38.97,18,,,percent of total billed charges,pays at 18% of total charges,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.25,50,,,percent of total billed charges,pays at 50% of total billed charges,151.55,70,,,percent of total billed charges,70% of total billed charges,162.38,75,,,percent of total billed charges,75% of total billed charges,108.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,173.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,216.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,194.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.93,216.5,
PEDI BIOPSY FORCEP,4152014,CDM,272,RC,,,Outpatient,,,211,126.6,,37.98,18,,,percent of total billed charges,pays at 18% of total charges,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.5,50,,,percent of total billed charges,pays at 50% of total billed charges,147.7,70,,,percent of total billed charges,70% of total billed charges,158.25,75,,,percent of total billed charges,75% of total billed charges,105.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,211,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.06,211,
3 LUMEN BALLOON CATHETER,4152015,CDM,272,RC,,,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,166.5,50,,,percent of total billed charges,pays at 50% of total billed charges,233.1,70,,,percent of total billed charges,70% of total billed charges,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.18,333,
KIT STARTER PLEURX,4152019,CDM,272,RC,,,Outpatient,,,1102.4,661.44,,198.43,18,,,percent of total billed charges,pays at 18% of total charges,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,198.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,551.2,50,,,percent of total billed charges,pays at 50% of total billed charges,771.68,70,,,percent of total billed charges,70% of total billed charges,826.8,75,,,percent of total billed charges,75% of total billed charges,551.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,881.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,843.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,661.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,418.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,771.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1102.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,992.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.75,1102.4,
THORACENTESIS KIT ARROW,4152020,CDM,272,RC,,,Outpatient,,,115.5,69.3,,20.79,18,,,percent of total billed charges,pays at 18% of total charges,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.75,50,,,percent of total billed charges,pays at 50% of total billed charges,80.85,70,,,percent of total billed charges,70% of total billed charges,86.63,75,,,percent of total billed charges,75% of total billed charges,57.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,115.5,
TRAY INSERTION PLEURX,4152021,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
SIX SHOOTER MULT LIGATOR,4152023,CDM,272,RC,,,Outpatient,,,903,541.8,,162.54,18,,,percent of total billed charges,pays at 18% of total charges,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,451.5,50,,,percent of total billed charges,pays at 50% of total billed charges,632.1,70,,,percent of total billed charges,70% of total billed charges,677.25,75,,,percent of total billed charges,75% of total billed charges,451.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,722.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,541.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,690.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,632.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,541.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,632.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,903,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,812.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.5,903,
RESOLUTION CLIP,4152025,CDM,272,RC,,,Outpatient,,,255,153,,45.9,18,,,percent of total billed charges,pays at 18% of total charges,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,127.5,50,,,percent of total billed charges,pays at 50% of total billed charges,178.5,70,,,percent of total billed charges,70% of total billed charges,191.25,75,,,percent of total billed charges,75% of total billed charges,127.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,204,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,153,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,195.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,255,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,229.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.96,255,
DEVICE ENDO CAPSULE DELIVERY,4152026,CDM,272,RC,,,Outpatient,,,244.5,146.7,,44.01,18,,,percent of total billed charges,pays at 18% of total charges,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.25,50,,,percent of total billed charges,pays at 50% of total billed charges,171.15,70,,,percent of total billed charges,70% of total billed charges,183.38,75,,,percent of total billed charges,75% of total billed charges,122.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,195.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,146.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,171.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,146.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,171.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,244.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,220.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.31,244.5,
DEVICE ENDO DIRECT SUCTION,4152027,CDM,272,RC,,,Outpatient,,,163.5,98.1,,29.43,18,,,percent of total billed charges,pays at 18% of total charges,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.75,50,,,percent of total billed charges,pays at 50% of total billed charges,114.45,70,,,percent of total billed charges,70% of total billed charges,122.63,75,,,percent of total billed charges,75% of total billed charges,81.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,130.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,125.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,147.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.62,163.5,
CATHETER PH/ IMPEDANCE DISPOSABLE,4152030,CDM,272,RC,,,Outpatient,,,157.5,94.5,,28.35,18,,,percent of total billed charges,pays at 18% of total charges,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.35,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.75,50,,,percent of total billed charges,pays at 50% of total billed charges,110.25,70,,,percent of total billed charges,70% of total billed charges,118.13,75,,,percent of total billed charges,75% of total billed charges,78.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,110.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,157.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,141.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,157.5,
PARACENTESIS/ PERITONEOCENTESIS,4153045,CDM,750,RC,,,Outpatient,,,1197.2,718.32,,215.5,18,,,percent of total billed charges,pays at 18% of total charges,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,598.6,50,,,percent of total billed charges,pays at 50% of total billed charges,838.04,70,,,percent of total billed charges,70% of total billed charges,897.9,75,,,percent of total billed charges,75% of total billed charges,598.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,957.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,718.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,915.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,838.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,718.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,454.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,838.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1197.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1077.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.6,1197.2,
UGI WITH BANDING,4153054,CDM,750,RC,,,Outpatient,,,2404.08,1442.45,,432.73,18,,,percent of total billed charges,pays at 18% of total charges,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,432.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1202.04,50,,,percent of total billed charges,pays at 50% of total billed charges,1682.86,70,,,percent of total billed charges,70% of total billed charges,1803.06,75,,,percent of total billed charges,75% of total billed charges,1202.04,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1923.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1839.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1442.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,913.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1682.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1153.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2404.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2163.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,376.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.72,2404.08,
CAPSULE ENDOSCOPY,4153057,CDM,750,RC,,,Outpatient,,,1373.68,824.21,,247.26,18,,,percent of total billed charges,pays at 18% of total charges,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,686.84,50,,,percent of total billed charges,pays at 50% of total billed charges,961.58,70,,,percent of total billed charges,70% of total billed charges,1030.26,75,,,percent of total billed charges,75% of total billed charges,686.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1098.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,824.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1050.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,961.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,824.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,522,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,961.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1373.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1236.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,215.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.26,1373.68,
GASTROESOPHAGEAL REFLUX PH TEST,4153058,CDM,750,RC,,,Outpatient,,,790.24,474.14,,142.24,18,,,percent of total billed charges,pays at 18% of total charges,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,395.12,50,,,percent of total billed charges,pays at 50% of total billed charges,553.17,70,,,percent of total billed charges,70% of total billed charges,592.68,75,,,percent of total billed charges,75% of total billed charges,395.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,632.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,474.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,604.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,553.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,474.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,300.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,553.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,790.24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,711.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.83,790.24,
BRUSH MICROBIOLOGY,4155000,CDM,270,RC,,,Outpatient,,,55,33,,9.9,18,,,percent of total billed charges,pays at 18% of total charges,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.5,50,,,percent of total billed charges,pays at 50% of total billed charges,38.5,70,,,percent of total billed charges,70% of total billed charges,41.25,75,,,percent of total billed charges,75% of total billed charges,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,55,
CO2 MONITORING NASAL CANNULA,4155002,CDM,272,RC,,,Outpatient,,,29.64,17.78,,5.34,18,,,percent of total billed charges,pays at 18% of total charges,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.82,50,,,percent of total billed charges,pays at 50% of total billed charges,20.75,70,,,percent of total billed charges,70% of total billed charges,22.23,75,,,percent of total billed charges,75% of total billed charges,14.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,29.64,
BRUSH CHANNEL WOOLY,4155003,CDM,270,RC,,,Outpatient,,,5.75,3.45,,1.04,18,,,percent of total billed charges,pays at 18% of total charges,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.88,50,,,percent of total billed charges,pays at 50% of total billed charges,4.03,70,,,percent of total billed charges,70% of total billed charges,4.31,75,,,percent of total billed charges,75% of total billed charges,2.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,5.75,
BLOCK BITE,4155004,CDM,270,RC,,,Outpatient,,,4.4,2.64,,0.79,18,,,percent of total billed charges,pays at 18% of total charges,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.2,50,,,percent of total billed charges,pays at 50% of total billed charges,3.08,70,,,percent of total billed charges,70% of total billed charges,3.3,75,,,percent of total billed charges,75% of total billed charges,2.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.69,4.4,
DEVICE DRAIN TUBE ATTACH,4155007,CDM,270,RC,,,Outpatient,,,13.55,8.13,,2.44,18,,,percent of total billed charges,pays at 18% of total charges,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.78,50,,,percent of total billed charges,pays at 50% of total billed charges,9.49,70,,,percent of total billed charges,70% of total billed charges,10.16,75,,,percent of total billed charges,75% of total billed charges,6.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.15,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,12.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.12,13.55,
DEVICE FEED TUBE ATTACH,4155008,CDM,270,RC,,,Outpatient,,,5.4,3.24,,0.97,18,,,percent of total billed charges,pays at 18% of total charges,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.97,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.7,50,,,percent of total billed charges,pays at 50% of total billed charges,3.78,70,,,percent of total billed charges,70% of total billed charges,4.05,75,,,percent of total billed charges,75% of total billed charges,2.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.85,5.4,
CONTAINER GLASS EVACUATED,4155009,CDM,272,RC,,,Outpatient,,,9.95,5.97,,1.79,18,,,percent of total billed charges,pays at 18% of total charges,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.98,50,,,percent of total billed charges,pays at 50% of total billed charges,6.97,70,,,percent of total billed charges,70% of total billed charges,7.46,75,,,percent of total billed charges,75% of total billed charges,4.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.97,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.95,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.56,9.95,
STOPCOCK THREE WAY,4155010,CDM,272,RC,,,Outpatient,,,5.5,3.3,,0.99,18,,,percent of total billed charges,pays at 18% of total charges,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.75,50,,,percent of total billed charges,pays at 50% of total billed charges,3.85,70,,,percent of total billed charges,70% of total billed charges,4.13,75,,,percent of total billed charges,75% of total billed charges,2.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,5.5,
CANNULA NASAL,4155011,CDM,270,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
NEBULIZER MIST,4155012,CDM,272,RC,,,Outpatient,,,1.6,0.96,,0.29,18,,,percent of total billed charges,pays at 18% of total charges,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.8,50,,,percent of total billed charges,pays at 50% of total billed charges,1.12,70,,,percent of total billed charges,70% of total billed charges,1.2,75,,,percent of total billed charges,75% of total billed charges,0.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.25,1.6,
ADAPTER FIBEROPTIC SWIVEL,4155013,CDM,272,RC,,,Outpatient,,,29.5,17.7,,5.31,18,,,percent of total billed charges,pays at 18% of total charges,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.75,50,,,percent of total billed charges,pays at 50% of total billed charges,20.65,70,,,percent of total billed charges,70% of total billed charges,22.13,75,,,percent of total billed charges,75% of total billed charges,14.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,20.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,29.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,29.5,
DRESSING TELFA,4155014,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
TUBE SUCTION YANKAUER,4155015,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
TRAP SPECIMEN MUCOUS,4155016,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CATH PH O2,4155017,CDM,272,RC,,,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,50,,,percent of total billed charges,pays at 50% of total billed charges,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
SPONGE DRAIN,4155018,CDM,272,RC,,,Outpatient,,,1.05,0.63,,0.19,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.19,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.53,50,,,percent of total billed charges,pays at 50% of total billed charges,0.74,70,,,percent of total billed charges,70% of total billed charges,0.79,75,,,percent of total billed charges,75% of total billed charges,0.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,0.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1.05,
TRAY SUTURE REMOVAL,4155019,CDM,272,RC,,,Outpatient,,,3.15,1.89,,0.57,18,,,percent of total billed charges,pays at 18% of total charges,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.58,50,,,percent of total billed charges,pays at 50% of total billed charges,2.21,70,,,percent of total billed charges,70% of total billed charges,2.36,75,,,percent of total billed charges,75% of total billed charges,1.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.49,3.15,
TUBE FEEDING,4155020,CDM,272,RC,,,Outpatient,,,53.5,32.1,,9.63,18,,,percent of total billed charges,pays at 18% of total charges,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.75,50,,,percent of total billed charges,pays at 50% of total billed charges,37.45,70,,,percent of total billed charges,70% of total billed charges,40.13,75,,,percent of total billed charges,75% of total billed charges,26.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,37.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,53.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,48.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,53.5,
PEG TUBE LOW PROFILE,4155021,CDM,272,RC,,,Outpatient,,,232.5,139.5,,41.85,18,,,percent of total billed charges,pays at 18% of total charges,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.25,50,,,percent of total billed charges,pays at 50% of total billed charges,162.75,70,,,percent of total billed charges,70% of total billed charges,174.38,75,,,percent of total billed charges,75% of total billed charges,116.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,186,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,139.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,177.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,232.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,209.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.43,232.5,
KIT PNEUMOTHORAX,4155022,CDM,272,RC,,,Outpatient,,,126,75.6,,22.68,18,,,percent of total billed charges,pays at 18% of total charges,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,63,50,,,percent of total billed charges,pays at 50% of total billed charges,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,96.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,113.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,126,
LINER SUCTION,4155023,CDM,272,RC,,,Outpatient,,,12.75,7.65,,2.3,18,,,percent of total billed charges,pays at 18% of total charges,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.38,50,,,percent of total billed charges,pays at 50% of total billed charges,8.93,70,,,percent of total billed charges,70% of total billed charges,9.56,75,,,percent of total billed charges,75% of total billed charges,6.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2,12.75,
TUBE NASOGASTRIC SUMP,4155024,CDM,270,RC,,,Outpatient,,,25,15,,4.5,18,,,percent of total billed charges,pays at 18% of total charges,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,12.5,50,,,percent of total billed charges,pays at 50% of total billed charges,17.5,70,,,percent of total billed charges,70% of total billed charges,18.75,75,,,percent of total billed charges,75% of total billed charges,12.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,20,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,17.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,22.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,25,
TUBE GASTRO 28FR,4155026,CDM,272,RC,,,Outpatient,,,423.8,254.28,,76.28,18,,,percent of total billed charges,pays at 18% of total charges,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.9,50,,,percent of total billed charges,pays at 50% of total billed charges,296.66,70,,,percent of total billed charges,70% of total billed charges,317.85,75,,,percent of total billed charges,75% of total billed charges,211.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,339.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,254.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,324.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,161.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,296.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,423.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,381.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.41,423.8,
GAUZE VASELINE,4155028,CDM,272,RC,,,Outpatient,,,6.5,3.9,,1.17,18,,,percent of total billed charges,pays at 18% of total charges,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.17,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.25,50,,,percent of total billed charges,pays at 50% of total billed charges,4.55,70,,,percent of total billed charges,70% of total billed charges,4.88,75,,,percent of total billed charges,75% of total billed charges,3.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.02,6.5,
TUBE CONNECTING STERILE,4155029,CDM,272,RC,,,Outpatient,,,18,10.8,,3.24,18,,,percent of total billed charges,pays at 18% of total charges,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9,50,,,percent of total billed charges,pays at 50% of total billed charges,12.6,70,,,percent of total billed charges,70% of total billed charges,13.5,75,,,percent of total billed charges,75% of total billed charges,9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,14.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.82,18,
SYSTEM DRAIN 3 CHAMBER,4155031,CDM,272,RC,,,Outpatient,,,81,48.6,,14.58,18,,,percent of total billed charges,pays at 18% of total charges,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.5,50,,,percent of total billed charges,pays at 50% of total billed charges,56.7,70,,,percent of total billed charges,70% of total billed charges,60.75,75,,,percent of total billed charges,75% of total billed charges,40.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.69,81,
CONNECTOR 5IN1 STRAIGHT,4155033,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
OXISENSOR ADULT,4155035,CDM,270,RC,,,Outpatient,,,61,36.6,,10.98,18,,,percent of total billed charges,pays at 18% of total charges,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.5,50,,,percent of total billed charges,pays at 50% of total billed charges,42.7,70,,,percent of total billed charges,70% of total billed charges,45.75,75,,,percent of total billed charges,75% of total billed charges,30.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,42.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.56,61,
PLATE ELECT SURG,4155036,CDM,272,RC,,,Outpatient,,,19,11.4,,3.42,18,,,percent of total billed charges,pays at 18% of total charges,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.5,50,,,percent of total billed charges,pays at 50% of total billed charges,13.3,70,,,percent of total billed charges,70% of total billed charges,14.25,75,,,percent of total billed charges,75% of total billed charges,9.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,15.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,14.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,13.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,19,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,17.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.98,19,
HOLDER LIMB WRIST,4155037,CDM,270,RC,,,Outpatient,,,21,12.6,,3.78,18,,,percent of total billed charges,pays at 18% of total charges,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.5,50,,,percent of total billed charges,pays at 50% of total billed charges,14.7,70,,,percent of total billed charges,70% of total billed charges,15.75,75,,,percent of total billed charges,75% of total billed charges,10.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,16.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,18.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.29,21,
DEVICE WIRE GUIDE LCKG,4155038,CDM,272,RC,C1769,HCPCS,Outpatient,,,35,21,,6.3,18,,,percent of total billed charges,pays at 18% of total charges,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.25,75,,,percent of total billed charges,75% of total billed charges,17.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,13.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,24.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,31.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,35,
BASKET EXTRACT LITHO,4155039,CDM,272,RC,,,Outpatient,,,423,253.8,,76.14,18,,,percent of total billed charges,pays at 18% of total charges,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.5,50,,,percent of total billed charges,pays at 50% of total billed charges,296.1,70,,,percent of total billed charges,70% of total billed charges,317.25,75,,,percent of total billed charges,75% of total billed charges,211.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,423,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.28,423,
VALVE SUCTION,4155041,CDM,272,RC,,,Outpatient,,,7,4.2,,1.26,18,,,percent of total billed charges,pays at 18% of total charges,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.5,50,,,percent of total billed charges,pays at 50% of total billed charges,4.9,70,,,percent of total billed charges,70% of total billed charges,5.25,75,,,percent of total billed charges,75% of total billed charges,3.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,7,
VALVE BIOPSY,4155042,CDM,272,RC,,,Outpatient,,,3,1.8,,0.54,18,,,percent of total billed charges,pays at 18% of total charges,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.54,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2.1,70,,,percent of total billed charges,70% of total billed charges,2.25,75,,,percent of total billed charges,75% of total billed charges,1.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.47,3,
FORCEP RADIAL JAW BIOPSY,4155043,CDM,272,RC,,,Outpatient,,,172,103.2,,30.96,18,,,percent of total billed charges,pays at 18% of total charges,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86,50,,,percent of total billed charges,pays at 50% of total billed charges,120.4,70,,,percent of total billed charges,70% of total billed charges,129,75,,,percent of total billed charges,75% of total billed charges,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,120.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,172,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,154.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,172,
ENDOBRONCHIAL CATHETER,4155045,CDM,272,RC,,,Outpatient,,,375,225,,67.5,18,,,percent of total billed charges,pays at 18% of total charges,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,187.5,50,,,percent of total billed charges,pays at 50% of total billed charges,262.5,70,,,percent of total billed charges,70% of total billed charges,281.25,75,,,percent of total billed charges,75% of total billed charges,187.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.76,375,
ROTH NET,4155046,CDM,272,RC,,,Outpatient,,,133.5,80.1,,24.03,18,,,percent of total billed charges,pays at 18% of total charges,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.75,50,,,percent of total billed charges,pays at 50% of total billed charges,93.45,70,,,percent of total billed charges,70% of total billed charges,100.13,75,,,percent of total billed charges,75% of total billed charges,66.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,106.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.73,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,133.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,120.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,133.5,
CHEST TUBE,4155047,CDM,272,RC,,,Outpatient,,,63,37.8,,11.34,18,,,percent of total billed charges,pays at 18% of total charges,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.5,50,,,percent of total billed charges,pays at 50% of total billed charges,44.1,70,,,percent of total billed charges,70% of total billed charges,47.25,75,,,percent of total billed charges,75% of total billed charges,31.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.87,63,
OVERTUBE,4155048,CDM,272,RC,,,Outpatient,,,283,169.8,,50.94,18,,,percent of total billed charges,pays at 18% of total charges,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.5,50,,,percent of total billed charges,pays at 50% of total billed charges,198.1,70,,,percent of total billed charges,70% of total billed charges,212.25,75,,,percent of total billed charges,75% of total billed charges,141.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,226.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,216.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,198.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,198.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,283,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,254.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.35,283,
FORCEPS HOT BX,4155049,CDM,272,RC,,,Outpatient,,,87.5,52.5,,15.75,18,,,percent of total billed charges,pays at 18% of total charges,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.75,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.75,50,,,percent of total billed charges,pays at 50% of total billed charges,61.25,70,,,percent of total billed charges,70% of total billed charges,65.63,75,,,percent of total billed charges,75% of total billed charges,43.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,66.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.25,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.71,87.5,
AMBU BAG,4155050,CDM,272,RC,,,Outpatient,,,68.5,41.1,,12.33,18,,,percent of total billed charges,pays at 18% of total charges,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.25,50,,,percent of total billed charges,pays at 50% of total billed charges,47.95,70,,,percent of total billed charges,70% of total billed charges,51.38,75,,,percent of total billed charges,75% of total billed charges,34.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,54.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,47.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,61.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,68.5,
SPOT DYE,4155051,CDM,272,RC,,,Outpatient,,,50,30,,9,18,,,percent of total billed charges,pays at 18% of total charges,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25,50,,,percent of total billed charges,pays at 50% of total billed charges,35,70,,,percent of total billed charges,70% of total billed charges,37.5,75,,,percent of total billed charges,75% of total billed charges,25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,50,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,50,
BONE MARROW KIT,4155052,CDM,272,RC,,,Outpatient,,,115,69,,20.7,18,,,percent of total billed charges,pays at 18% of total charges,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.5,50,,,percent of total billed charges,pays at 50% of total billed charges,80.5,70,,,percent of total billed charges,70% of total billed charges,86.25,75,,,percent of total billed charges,75% of total billed charges,57.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.02,115,
TUBE ESOPH BLAKEMORE,4155053,CDM,272,RC,,,Outpatient,,,422.5,253.5,,76.05,18,,,percent of total billed charges,pays at 18% of total charges,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.05,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,211.25,50,,,percent of total billed charges,pays at 50% of total billed charges,295.75,70,,,percent of total billed charges,70% of total billed charges,316.88,75,,,percent of total billed charges,75% of total billed charges,211.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,338,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,253.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,295.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.55,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,295.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,422.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,380.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.21,422.5,
STENT ESOPHAGEAL,4155054,CDM,278,RC,,,Outpatient,,,2025,1215,,364.5,18,,,percent of total billed charges,pays at 18% of total charges,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,364.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1012.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1417.5,70,,,percent of total billed charges,70% of total billed charges,1518.75,75,,,percent of total billed charges,75% of total billed charges,1012.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1620,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1215,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2025,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1417.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1215,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,769.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1417.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,972,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2025,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,317.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.32,2025,
SYRINGE DILATION,4155055,CDM,272,RC,,,Outpatient,,,55,33,,9.9,18,,,percent of total billed charges,pays at 18% of total charges,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.5,50,,,percent of total billed charges,pays at 50% of total billed charges,38.5,70,,,percent of total billed charges,70% of total billed charges,41.25,75,,,percent of total billed charges,75% of total billed charges,27.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,38.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,55,
ESOPH W STENT PLACEMENT,4155056,CDM,750,RC,,,Outpatient,,,3578.4,2147.04,,644.11,18,,,percent of total billed charges,pays at 18% of total charges,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,644.11,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1789.2,50,,,percent of total billed charges,pays at 50% of total billed charges,2504.88,70,,,percent of total billed charges,70% of total billed charges,2683.8,75,,,percent of total billed charges,75% of total billed charges,1789.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2862.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2147.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2737.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1610.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2504.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2147.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1359.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2504.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1717.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3578.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3220.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,560.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.74,3578.4,
BAND LIGATOR,4155057,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
ELEVIEW INJECTION,4155058,CDM,272,RC,,,Outpatient,,,122,73.2,,21.96,18,,,percent of total billed charges,pays at 18% of total charges,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61,50,,,percent of total billed charges,pays at 50% of total billed charges,85.4,70,,,percent of total billed charges,70% of total billed charges,91.5,75,,,percent of total billed charges,75% of total billed charges,61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,122,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,109.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.12,122,
ILEOSCOPY or COLONOSCOPY THRU STOMA,4159089,CDM,750,RC,,,Outpatient,,,1646.64,987.98,,296.4,18,,,percent of total billed charges,pays at 18% of total charges,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,823.32,50,,,percent of total billed charges,pays at 50% of total billed charges,1152.65,70,,,percent of total billed charges,70% of total billed charges,1234.98,75,,,percent of total billed charges,75% of total billed charges,823.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1317.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,987.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1259.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1152.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,987.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,625.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1152.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,790.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1646.64,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1481.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,258.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.03,1646.64,
LIVER ELASTOGRAPHY/INTER (FIBROSCAN),4159091,CDM,750,RC,91200,HCPCS,Outpatient,,,428,256.8,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,299.6,70,,,percent of total billed charges,70% of total billed charges,321,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,342.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.85,103,,,Fee Schedule,103% of CMS OPPS Rate,327.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,192.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,299.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,256.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,162.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,299.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.08,100,,,Fee Schedule,100% of CMS OPPS Rate,205.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,385.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,67.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,468.02,
RADIAL EBUS TBNA NDL,4159092,CDM,272,RC,,,Outpatient,,,413,247.8,,74.34,18,,,percent of total billed charges,pays at 18% of total charges,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,206.5,50,,,percent of total billed charges,pays at 50% of total billed charges,289.1,70,,,percent of total billed charges,70% of total billed charges,309.75,75,,,percent of total billed charges,75% of total billed charges,206.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,330.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,247.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,315.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,289.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,156.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,289.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,413,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,371.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.72,413,
RADIAL EBUS SHEATH KIT,4159093,CDM,272,RC,,,Outpatient,,,195,117,,35.1,18,,,percent of total billed charges,pays at 18% of total charges,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97.5,50,,,percent of total billed charges,pays at 50% of total billed charges,136.5,70,,,percent of total billed charges,70% of total billed charges,146.25,75,,,percent of total billed charges,75% of total billed charges,97.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,136.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,136.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,195,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,175.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,195,
RADIAL EBUS GUIDING DEVICES,4159094,CDM,272,RC,,,Outpatient,,,771,462.6,,138.78,18,,,percent of total billed charges,pays at 18% of total charges,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,138.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,385.5,50,,,percent of total billed charges,pays at 50% of total billed charges,539.7,70,,,percent of total billed charges,70% of total billed charges,578.25,75,,,percent of total billed charges,75% of total billed charges,385.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,616.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,589.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,539.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,462.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,292.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,539.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,771,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,693.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.82,771,
EXALT ERCP SCOPE,4159095,CDM,278,RC,C1748,HCPCS,Outpatient,,,7325,4395,,1318.5,18,,,percent of total billed charges,pays at 18% of total charges,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3662.5,50,,,percent of total billed charges,pays at 50% of total billed charges,5127.5,70,,,percent of total billed charges,70% of total billed charges,5493.75,75,,,percent of total billed charges,75% of total billed charges,3662.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5860,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4395,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7325,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1262.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3296.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5127.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4395,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2783.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5127.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3516,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,7325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1147.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1147.83,7325,
"PUNCH BIOPSY, SINGLE",4159096,CDM,510,RC,11104,HCPCS,Outpatient,,,402.7,241.62,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,1200.6,
LUMBAR PUNCTURE,4159097,CDM,360,RC,,,Outpatient,,,960,576,,172.8,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,172.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,480,50,,,percent of total billed charges,pays at 50% of total billed charges,672,70,,,percent of total billed charges,70% of total billed charges,720,75,,,percent of total billed charges,75% of total billed charges,480,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,768,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,734.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,960,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,864,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,960,
MANDIBLE 1-4 VWS,4200100,CDM,320,RC,70100,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
MANDIBLE COMPLETE,4200110,CDM,320,RC,70110,HCPCS,Outpatient,,,419.32,251.59,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,293.52,70,,,percent of total billed charges,70% of total billed charges,314.49,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,335.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,320.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,188.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,293.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,293.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,201.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.71,377.39,
MASTOIDS COMPLETE,4200130,CDM,320,RC,70130,HCPCS,Outpatient,,,262,157.2,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.4,70,,,percent of total billed charges,70% of total billed charges,196.5,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,200.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,117.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,125.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,41.06,364,
FACIAL BONES <3 VIEWS,4200140,CDM,320,RC,70140,HCPCS,Outpatient,,,400,240,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,62.68,364,
FACIAL BONES COMPLETE,4200150,CDM,320,RC,70150,HCPCS,Outpatient,,,419.32,251.59,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,293.52,70,,,percent of total billed charges,70% of total billed charges,314.49,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,335.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,320.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,188.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,293.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,293.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,201.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.71,377.39,
NASAL BONES COMPLETE,4200160,CDM,320,RC,70160,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
ORBITS COMPLETE,4200200,CDM,320,RC,70200,HCPCS,Outpatient,,,369.6,221.76,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,258.72,70,,,percent of total billed charges,70% of total billed charges,277.2,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,295.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,282.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,166.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,258.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,258.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,177.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,332.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,57.92,364,
SINUSES 1-3 VWS,4200210,CDM,320,RC,70210,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
SINUSES COMPLETE,4200220,CDM,320,RC,70220,HCPCS,Outpatient,,,524.15,314.49,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,366.91,70,,,percent of total billed charges,70% of total billed charges,393.11,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,419.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,400.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,235.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,366.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,314.49,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,366.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,251.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,471.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,471.74,
SKULL 1-4 VWS,4200250,CDM,320,RC,70250,HCPCS,Outpatient,,,332.55,199.53,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,232.79,70,,,percent of total billed charges,70% of total billed charges,249.41,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,266.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,254.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,149.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,232.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,232.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,159.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,299.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,52.11,364,
SKULL COMPLETE,4200260,CDM,320,RC,70260,HCPCS,Outpatient,,,462,277.2,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,323.4,70,,,percent of total billed charges,70% of total billed charges,346.5,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,369.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,353.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,79.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,323.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,221.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,415.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,72.4,415.8,
T-M JOINTS BILAT,4200330,CDM,320,RC,70330,HCPCS,Outpatient,,,454.85,272.91,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,318.4,70,,,percent of total billed charges,70% of total billed charges,341.14,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,363.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,347.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,78.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,204.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,318.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,272.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,318.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,218.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,409.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,71.27,409.37,
NECK-SOFT TISSUE,4200360,CDM,320,RC,70360,HCPCS,Outpatient,,,293.15,175.89,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.21,70,,,percent of total billed charges,70% of total billed charges,219.86,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,224.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,205.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,140.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,263.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45.94,364,
INJECT FOR PYELOGRAPHY,4200394,CDM,320,RC,50430,HCPCS,Outpatient,,,144.57,86.74,,2012.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,144.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1153.2,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,101.2,70,,,percent of total billed charges,70% of total billed charges,108.43,75,,,percent of total billed charges,75% of total billed charges,1023.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1989.73,350,,,Fee Schedule,350% of CMS OPPS Rate,144.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,65.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,101.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,101.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1307.54,100,,,Fee Schedule,100% of CMS OPPS Rate,69.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144.57,100,,,Fee Schedule,100% of CMS OPPS Rate,130.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,22.65,2012.47,
FISTULA/SINUS TRACT,4200501,CDM,320,RC,20501,HCPCS,Outpatient,,,165.44,99.26,,29.78,18,,,percent of total billed charges,pays at 18% of total charges,165.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,115.81,70,,,percent of total billed charges,70% of total billed charges,124.08,75,,,percent of total billed charges,75% of total billed charges,82.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,115.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,165.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,148.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.78,473.66,
Draining or injecting medication into a large joint/bursa without ultrasound,4200605,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a major joint/bursa without ultrasound,4200610,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Single view,4201010,CDM,324,RC,71045,HCPCS,Outpatient,,,216,129.6,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,80.55,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
Single view,4201010,CDM,324,RC,71045,HCPCS,Outpatient,,,,,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
"2 views, front and back",4201020,CDM,324,RC,71046,HCPCS,Outpatient,,,376.6,225.96,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,263.62,70,,,percent of total billed charges,70% of total billed charges,282.45,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,301.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,80.55,103,,,Fee Schedule,103% of CMS OPPS Rate,288.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,169.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,263.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,180.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,338.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,59.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,59.01,364,
3 views,4201021,CDM,324,RC,71047,HCPCS,Outpatient,,,205.92,123.55,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.14,70,,,percent of total billed charges,70% of total billed charges,154.44,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,164.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,157.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,92.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,144.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,98.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,185.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,32.27,364,
4 or more views,4201022,CDM,324,RC,71048,HCPCS,Outpatient,,,200,120,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,31.34,364,
"2 views, front and back",4201023,CDM,324,RC,71046,HCPCS,Outpatient,,,240,144,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168,70,,,percent of total billed charges,70% of total billed charges,180,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,80.55,103,,,Fee Schedule,103% of CMS OPPS Rate,183.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,108,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,216,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,37.61,364,
4 or more views,4201030,CDM,324,RC,71048,HCPCS,Outpatient,,,238.4,143.04,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,166.88,70,,,percent of total billed charges,70% of total billed charges,178.8,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,190.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,182.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,107.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,166.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,143.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,166.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,114.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,214.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,37.36,364,
4 or more views,4201035,CDM,324,RC,71048,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
RIBS UNILAT 2-VWS,4201100,CDM,320,RC,71100,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
RIBS UNILAT 2-VWS RIGHT,4201100RT,CDM,320,RC,71100,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of one side of the chest/ribs,4201101,CDM,320,RC,71101,HCPCS,Outpatient,,,280,168,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,364,
Radiologic examination of one side of the chest/ribs,420-1101,CDM,320,RC,71101,HCPCS,Outpatient,,,282.04,169.22,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
RIBS BILAT 3-VWS,4201110,CDM,320,RC,71110,HCPCS,Outpatient,,,369.6,221.76,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,258.72,70,,,percent of total billed charges,70% of total billed charges,277.2,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,295.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,282.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,166.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,258.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,258.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,177.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,332.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,57.92,364,
RIBS BILAT WITH 1V CHEST,4201111,CDM,320,RC,71111,HCPCS,Outpatient,,,400,240,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.68,364,
STERNUM,4201120,CDM,320,RC,71120,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
STERNOCLAVICULAR JOINTS,4201130,CDM,320,RC,71130,HCPCS,Outpatient,,,245.08,147.05,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,171.56,70,,,percent of total billed charges,70% of total billed charges,183.81,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,196.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,187.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,110.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,171.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,171.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,117.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,220.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,38.4,364,
INJ FOR CYSTOGRAM,4201600,CDM,320,RC,51600,HCPCS,Outpatient,,,105.2,63.12,,18.94,18,,,percent of total billed charges,pays at 18% of total charges,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,73.64,70,,,percent of total billed charges,70% of total billed charges,78.9,75,,,percent of total billed charges,75% of total billed charges,52.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,84.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,73.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,94.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.48,473.66,
SPINE 1 VIEW SPECIFY LEVEL,4202020,CDM,320,RC,72020,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
"Radiologic examination of the neck/spine, 2-3 views",4202040,CDM,320,RC,72040,HCPCS,Outpatient,,,293.15,175.89,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.21,70,,,percent of total billed charges,70% of total billed charges,219.86,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,224.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,205.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,140.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,263.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45.94,364,
"Radiologic examination of the neck/spine, 4-5 views",4202050,CDM,320,RC,72050,HCPCS,Outpatient,,,419.32,251.59,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,293.52,70,,,percent of total billed charges,70% of total billed charges,314.49,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,335.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,320.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,188.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,293.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,251.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,293.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,201.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.71,377.39,
SPINE-CERVICAL-OBL-FL-EXT,4202052,CDM,320,RC,72052,HCPCS,Outpatient,,,506.44,303.86,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,354.51,70,,,percent of total billed charges,70% of total billed charges,379.83,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,405.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,387.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,227.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,354.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,243.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,455.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,79.36,455.8,
"Radiologic examination of the middle spine, 2 views",4202070,CDM,320,RC,72070,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
"Radiologic examination of the middle spine, 3 views",4202072,CDM,320,RC,72072,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
SCOLIOSIS STUDY-SPINE,4202090,CDM,320,RC,72081,HCPCS,Outpatient,,,414.36,248.62,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,290.05,70,,,percent of total billed charges,70% of total billed charges,310.77,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,331.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,316.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,186.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,290.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,198.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,372.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,64.93,372.92,
X-ray of the lower spine 2-3 views,4202100,CDM,320,RC,72100,HCPCS,Outpatient,,,329.67,197.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,230.77,70,,,percent of total billed charges,70% of total billed charges,247.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,263.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,252.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,148.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,230.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,158.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,296.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.66,364,
"X-ray of lower and sacral spine, minimum of 4 views",4202110,CDM,320,RC,72110,HCPCS,Outpatient,,,506.44,303.86,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,354.51,70,,,percent of total billed charges,70% of total billed charges,379.83,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,405.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,387.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,227.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,303.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,354.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,243.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,455.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,79.36,455.8,
SPINE-LS COMPL W/BENDING,4202114,CDM,320,RC,72114,HCPCS,Outpatient,,,608.96,365.38,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,426.27,70,,,percent of total billed charges,70% of total billed charges,456.72,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,487.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,465.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,274.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,426.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,365.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,426.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,292.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,548.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,95.42,548.06,
SPINE-LS BENDING ONLY,4202120,CDM,320,RC,72120,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
Radiologic examination of the pelvis,4202170,CDM,320,RC,72170,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
PELVIS - 3 VIEW,4202190,CDM,320,RC,72190,HCPCS,Outpatient,,,261.72,157.03,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.2,70,,,percent of total billed charges,70% of total billed charges,196.29,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,200.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,117.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,183.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,125.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,41.01,364,
SACROILIAC JNTS: 3 OR >VW,4202202,CDM,320,RC,72202,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
SACRUM/COCCYX,4202220,CDM,320,RC,72220,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
MYELO INJ SPINE NOT C1-C2,4202284,CDM,360,RC,62284,HCPCS,Outpatient,,,869.44,521.66,,156.5,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,156.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,608.61,70,,,percent of total billed charges,70% of total billed charges,652.08,75,,,percent of total billed charges,75% of total billed charges,434.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,695.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,521.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,665.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,608.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,521.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,608.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,869.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,782.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.5,930.49,
Radiologic examination of the collar bone,4203000,CDM,320,RC,73000,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the collar bone,4203000RT,CDM,320,RC,73000,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
SCAPULA,4203010,CDM,320,RC,73010,HCPCS,Outpatient,,,230.76,138.46,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,161.53,70,,,percent of total billed charges,70% of total billed charges,173.07,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,184.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,176.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,103.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,161.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,110.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,36.16,364,
SHOULDER 1-VW LEFT,4203020,CDM,320,RC,73020,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
SHOULDER 1-VW RIGHT,4203020RT,CDM,320,RC,73020,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
Radiologic examination of the shoulder,4203030,CDM,320,RC,73030,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the shoulder,4203030RT,CDM,320,RC,73030,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
"ACJ, BIL, W/WO WEIGHT BILATERAL",4203050BIL,CDM,320,RC,73050,HCPCS,Outpatient,,,369.6,221.76,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,258.72,70,,,percent of total billed charges,70% of total billed charges,277.2,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,295.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,282.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,166.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,258.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,258.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,177.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,332.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.92,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,57.92,364,
HUMERUS LEFT,4203060,CDM,320,RC,73060,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
HUMERUS RIGHT,4203060RT,CDM,320,RC,73060,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
"Radiologic examination, elbow; 2 views",4203070,CDM,320,RC,73070,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
"Radiologic examination, elbow; 2 views",4203070RT,CDM,320,RC,73070,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
"Radiologic examination, elbow; 3 or more views",4203080,CDM,320,RC,73080,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
"Radiologic examination, elbow; 3 or more views",4203080RT,CDM,320,RC,73080,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the forearm,4203090,CDM,320,RC,73090,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the forearm,4203090RT,CDM,320,RC,73090,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
UEXTREM INFANT 2V LT,4203092,CDM,320,RC,73092,HCPCS,Outpatient,,,168,100.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.6,70,,,percent of total billed charges,70% of total billed charges,126,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,128.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,75.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,80.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,151.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,364,
UEXTREM INFANT 2V RT,4203092RT,CDM,320,RC,73092,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
Up to 3 views,4203110,CDM,320,RC,73110,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Up to 3 views,4203110RT,CDM,320,RC,73110,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
X-ray of the hand with 3 or more views,4203130,CDM,320,RC,73130,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
X-ray of the hand with 3 or more views,4203130RT,CDM,320,RC,73130,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
"2 views, front and back",4203135,CDM,324,RC,71046,HCPCS,Outpatient,,,,,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the finger(s),4203140,CDM,320,RC,73140,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the finger(s),4203140RT,CDM,320,RC,73140,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
SHOULDER ARTHRO INJ LT,4203350,CDM,320,RC,23350,HCPCS,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,515.31,
SHOULDER ARTHRO INJ RIGHT,4203350RT,CDM,320,RC,23350,HCPCS,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,515.31,
HIP UNIL 1-VW LEFT,4203500,CDM,320,RC,73501,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
HIP UNIL 1-VW RIGHT,4203500RT,CDM,320,RC,73501,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
HIP COMPLETE LEFT,4203510,CDM,320,RC,73502,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
HIP COMPLETE RIGHT,4203510RT,CDM,320,RC,73502,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
HIP BILAT 2V,4203520,CDM,320,RC,73521,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
HIP BILAT 3-4V,4203522,CDM,320,RC,73522,HCPCS,Outpatient,,,270.6,162.36,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,189.42,70,,,percent of total billed charges,70% of total billed charges,202.95,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,216.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,207.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,121.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,189.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,189.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,129.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,243.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,42.4,364,
OR HIP LEFT,4203530,CDM,320,RC,73501,HCPCS,Outpatient,,,473.88,284.33,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,331.72,70,,,percent of total billed charges,70% of total billed charges,355.41,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,379.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,362.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,213.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,331.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,227.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,426.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,74.26,426.49,
OR HIP RIGHT,4203530RT,CDM,320,RC,73501,HCPCS,Outpatient,,,473.88,284.33,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,331.72,70,,,percent of total billed charges,70% of total billed charges,355.41,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,379.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,362.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,213.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,331.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,227.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,426.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,74.26,426.49,
PELVIS/HIPS CHILD,4203540,CDM,320,RC,73502,HCPCS,Outpatient,,,256.4,153.84,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.48,70,,,percent of total billed charges,70% of total billed charges,192.3,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,205.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,196.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,115.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,179.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,123.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,230.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,40.18,364,
"FEMUR, 2 VIEWS LEFT",4203550,CDM,320,RC,73552,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
"FEMUR, 2 VIEWS RIGHT",4203550RT,CDM,320,RC,73552,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the knee with 1 or 2 views,4203560,CDM,320,RC,73560,HCPCS,Outpatient,,,278.49,167.09,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,194.94,70,,,percent of total billed charges,70% of total billed charges,208.87,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,222.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,213.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,125.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,194.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,250.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.64,364,
Radiologic examination of the knee with 1 or 2 views,4203560RT,CDM,320,RC,73560,HCPCS,Outpatient,,,278.49,167.09,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,194.94,70,,,percent of total billed charges,70% of total billed charges,208.87,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,222.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,213.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,125.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,167.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,194.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,133.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,250.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.64,364,
Radiologic examination of the knee with 3 views,4203562,CDM,320,RC,73562,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of both knees,4203565,CDM,320,RC,73565,HCPCS,Outpatient,,,130.24,78.14,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,91.17,70,,,percent of total billed charges,70% of total billed charges,97.68,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,99.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,58.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,91.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,62.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,117.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.41,364,
Radiologic examination of the knee with 4 or more views,4203570,CDM,320,RC,73564,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
Radiologic examination of the knee with 4 or more views,4203570RT,CDM,320,RC,73564,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
Radiologic examination of the lower leg,4203590,CDM,320,RC,73590,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the lower leg,4203590RT,CDM,320,RC,73590,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
LOWER EXT INFANT,4203592,CDM,320,RC,73592,HCPCS,Outpatient,,,149.76,89.86,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.83,70,,,percent of total billed charges,70% of total billed charges,112.32,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,114.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,67.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,104.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,71.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,134.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,23.47,364,
"STRESS VIEW(S), ANY JOINT LEFT",4203600,CDM,320,RC,77071,HCPCS,Outpatient,,,95.6,57.36,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.92,70,,,percent of total billed charges,70% of total billed charges,71.7,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,73.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,66.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,86.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,364,
"STRESS VIEW(S), ANY JOINT RIGHT",4203600RT,CDM,320,RC,77071,HCPCS,Outpatient,,,95.6,57.36,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.92,70,,,percent of total billed charges,70% of total billed charges,71.7,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,73.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,66.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,45.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,86.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,14.98,364,
Radiologic examination of the ankle with 3 views,4203610,CDM,320,RC,73610,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the ankle with 3 views,4203610RT,CDM,320,RC,73610,HCPCS,Outpatient,,,282.04,169.22,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,197.43,70,,,percent of total billed charges,70% of total billed charges,211.53,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,225.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,215.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,126.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,169.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,197.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,135.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,44.2,364,
Radiologic examination of the foot with 3 or more views,4203630,CDM,320,RC,73630,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the foot with 3 or more views,4203630RT,CDM,320,RC,73630,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the heel,4203650,CDM,320,RC,73650,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the heel,4203650RT,CDM,320,RC,73650,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the toe(s),4203660,CDM,320,RC,73660,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
Radiologic examination of the toe(s),4203660RT,CDM,320,RC,73660,HCPCS,Outpatient,,,234.52,140.71,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,164.16,70,,,percent of total billed charges,70% of total billed charges,175.89,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,187.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,179.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,105.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,164.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,112.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,211.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.75,364,
ABDOMEN AP VIEW,4204000,CDM,320,RC,74018,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
ABD COMP W DECUB R EREC,4204020,CDM,320,RC,74019,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
Serial radiologic examination of the abdomen,4204022,CDM,320,RC,74022,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
CHOLANGIOGRAM INTRAOP,4204300,CDM,320,RC,74300,HCPCS,Outpatient,,,268.56,161.14,,48.34,18,,,percent of total billed charges,pays at 18% of total charges,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.34,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.99,70,,,percent of total billed charges,70% of total billed charges,201.42,75,,,percent of total billed charges,75% of total billed charges,134.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,214.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,187.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,187.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,268.56,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,241.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.08,364,
IVP,4204400,CDM,320,RC,74400,HCPCS,Outpatient,,,608.96,365.38,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,426.27,70,,,percent of total billed charges,70% of total billed charges,456.72,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,487.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,465.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,274.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,426.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,365.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,426.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,292.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,548.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,95.42,580.36,
SHUNTOGRAM,4205809,CDM,320,RC,75809,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
EXTREM VENOGRAM INJ LT,4206005,CDM,320,RC,36005,HCPCS,Outpatient,,,2000,1200,,360,18,,,percent of total billed charges,pays at 18% of total charges,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.4,2000,
EXTREM VENOGRAM INJ RIGHT,4206005RT,CDM,320,RC,36005,HCPCS,Outpatient,,,2000,1200,,360,18,,,percent of total billed charges,pays at 18% of total charges,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.4,2000,
1 VIEW CHILD FOREIGN BDY,4206010,CDM,320,RC,76010,HCPCS,Outpatient,,,100.35,60.21,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70.25,70,,,percent of total billed charges,70% of total billed charges,75.26,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,76.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,70.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,48.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,90.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,364,
BONE AGE STUDY,4206020,CDM,320,RC,77072,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
BONE LENGTH STUDY,4206040,CDM,320,RC,77073,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
BONE LENGTH STUDY RIGHT,4206040RT,CDM,320,RC,77073,HCPCS,Outpatient,,,213.2,127.92,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.24,70,,,percent of total billed charges,70% of total billed charges,159.9,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,170.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,163.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,95.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,149.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,102.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,33.41,364,
BONE SURVEY METABOLIC,4206061,CDM,320,RC,77074,HCPCS,Outpatient,,,450.4,270.24,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,315.28,70,,,percent of total billed charges,70% of total billed charges,337.8,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,360.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,344.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,202.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,315.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,216.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,405.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.58,405.36,
BONE SURVEY METASTASES,4206062,CDM,320,RC,77075,HCPCS,Outpatient,,,518.04,310.82,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,362.63,70,,,percent of total billed charges,70% of total billed charges,388.53,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,414.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,396.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,233.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,362.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,310.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,362.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,248.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,466.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.18,466.24,
BONE SURVEY INFANT,4206065,CDM,320,RC,77076,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
LUMBAR PUNCTURE,4206227,CDM,360,RC,62328,HCPCS,Outpatient,,,1692,1015.2,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,846,50,,,percent of total billed charges,pays at 50% of total billed charges,1184.4,70,,,percent of total billed charges,70% of total billed charges,1269,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,1294.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,761.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1015.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,812.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1522.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,2073.62,
"JOINT SURVEY, SINGLE VIEW",4207077,CDM,320,RC,77077,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
TRAY MYELGRAM,4207299,CDM,272,RC,,,Outpatient,,,320.5,192.3,,57.69,18,,,percent of total billed charges,pays at 18% of total charges,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.25,50,,,percent of total billed charges,pays at 50% of total billed charges,224.35,70,,,percent of total billed charges,70% of total billed charges,240.38,75,,,percent of total billed charges,75% of total billed charges,160.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,224.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,320.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,288.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,320.5,
TRAY HYSTERO,4207399,CDM,272,RC,,,Outpatient,,,119.9,71.94,,21.58,18,,,percent of total billed charges,pays at 18% of total charges,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.95,50,,,percent of total billed charges,pays at 50% of total billed charges,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,59.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,119.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,119.9,
HYSTEROG/SIS CONTR/SALINE,4208340,CDM,360,RC,58340,HCPCS,Outpatient,,,277.2,166.32,,49.9,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,49.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,194.04,70,,,percent of total billed charges,70% of total billed charges,207.9,75,,,percent of total billed charges,75% of total billed charges,138.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,194.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,249.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.9,657,
PORTABLE,4208888,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
HSG CATHETER,4209042,CDM,272,RC,,,Outpatient,,,149.05,89.43,,26.83,18,,,percent of total billed charges,pays at 18% of total charges,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.53,50,,,percent of total billed charges,pays at 50% of total billed charges,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,74.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.36,149.05,
3 or more views,4209427,CDM,320,RC,73100,HCPCS,Outpatient,,,230.42,138.25,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,161.29,70,,,percent of total billed charges,70% of total billed charges,172.82,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,184.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,176.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,103.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,161.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,110.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,207.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.11,364,
3 or more views,4209427RT,CDM,320,RC,73100,HCPCS,Outpatient,,,230.42,138.25,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,161.29,70,,,percent of total billed charges,70% of total billed charges,172.82,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,184.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,176.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,103.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,161.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,138.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,161.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,110.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,207.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,36.11,364,
X-ray of the hand with 2 views,4209429,CDM,320,RC,73120,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
X-ray of the hand with 2 views,4209429RT,CDM,320,RC,73120,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
Radiologic examination of the ankle with 2 views,4209442,CDM,320,RC,73600,HCPCS,Outpatient,,,218.4,131.04,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.88,70,,,percent of total billed charges,70% of total billed charges,163.8,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,174.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,167.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,98.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,152.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,152.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,34.22,364,
Radiologic examination of the ankle with 2 views,4209442RT,CDM,320,RC,73600,HCPCS,Outpatient,,,218.4,131.04,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.88,70,,,percent of total billed charges,70% of total billed charges,163.8,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,174.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,167.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,98.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,152.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,152.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,104.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,196.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,34.22,364,
"Radiologic examination, foot; 2 views",4209445,CDM,320,RC,73620,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,364,
"Radiologic examination, foot; 2 views",4209445RT,CDM,320,RC,73620,HCPCS,Outpatient,,,168,100.8,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,117.6,70,,,percent of total billed charges,70% of total billed charges,126,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,134.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,128.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,75.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,100.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,117.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,80.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,151.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.33,364,
MYELO CERV PUNCTURE,4211055,CDM,320,RC,61055,HCPCS,Outpatient,,,674,404.4,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,674,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,471.8,70,,,percent of total billed charges,70% of total billed charges,505.5,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,539.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,515.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,303.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,471.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,404.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,471.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,323.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,606.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,674,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,4218006,CDM,340,RC,78014,HCPCS,Outpatient,,,1433.3,859.98,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1003.31,70,,,percent of total billed charges,70% of total billed charges,1074.98,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1146.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1096.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,644.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1003.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,859.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1003.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,687.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.6,1762,
NM*THYROID IMAGING ONLY,4218010,CDM,340,RC,78013,HCPCS,Outpatient,,,671,402.6,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,469.7,70,,,percent of total billed charges,70% of total billed charges,503.25,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,536.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,513.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,301.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,469.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,402.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,469.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,322.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,603.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,105.15,1762,
THYROID IMAGING FU,4218011,CDM,341,RC,78018,HCPCS,Outpatient,,,1278,766.8,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,894.6,70,,,percent of total billed charges,70% of total billed charges,958.5,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,977.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,575.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,894.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,766.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,894.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,613.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1150.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,200.26,1762,
THYROID METS; WHOLE BODY,421-8018,CDM,340,RC,78018,HCPCS,Outpatient,,,1495,897,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1046.5,70,,,percent of total billed charges,70% of total billed charges,1121.25,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1196,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,1143.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,257.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,672.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1046.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,897,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1046.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,717.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1345.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,234.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,234.27,1762,
NM THYROID MET 48 IMAGING,421-8019,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PARATHYROID IMAGING,4218070,CDM,341,RC,78070,HCPCS,Outpatient,,,603.9,362.34,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,422.73,70,,,percent of total billed charges,70% of total billed charges,452.93,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,483.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,461.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,104.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,271.76,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,422.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,362.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,422.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,289.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,543.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,94.63,1762,
PARATHYROID IMAGING W SPECT,4218071,CDM,341,RC,78071,HCPCS,Outpatient,,,1433.3,859.98,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1003.31,70,,,percent of total billed charges,70% of total billed charges,1074.98,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1146.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1096.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,644.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1003.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,859.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1003.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,687.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.6,1762,
Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,4218104,CDM,341,RC,78014,HCPCS,Outpatient,,,1433.3,859.98,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1003.31,70,,,percent of total billed charges,70% of total billed charges,1074.98,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1146.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1096.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,644.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1003.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,859.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1003.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,687.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.6,1762,
NM*LYMPH NODE IMAGING,4218194,CDM,341,RC,78195,HCPCS,Outpatient,,,592.35,355.41,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,414.65,70,,,percent of total billed charges,70% of total billed charges,444.26,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,473.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,453.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,102.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,266.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,414.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,355.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,414.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,284.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,533.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,92.82,1762,
SPECT-LIVER (HEMANG) IMAG,4218205,CDM,341,RC,78803,HCPCS,Outpatient,,,1523.5,914.1,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1066.45,70,,,percent of total billed charges,70% of total billed charges,1142.63,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1218.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1165.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,262.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,685.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1066.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,914.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1066.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,731.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1371.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,238.73,4271.43,
NM*LIVER/SPLEEN IMAGING,4218215,CDM,341,RC,78215,HCPCS,Outpatient,,,1392.75,835.65,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,974.93,70,,,percent of total billed charges,70% of total billed charges,1044.56,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1114.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1065.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,239.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,626.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,974.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,835.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,974.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,668.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1253.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,218.24,1762,
HIDA-SCAN-GB W/ KINEVAC,4218223,CDM,341,RC,78227,HCPCS,Outpatient,,,1800,1080,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1260,70,,,percent of total billed charges,70% of total billed charges,1350,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,1377,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,310.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,282.06,1762,
HIDA-SCAN-GB W/O KINEVAC,4218226,CDM,341,RC,78226,HCPCS,Outpatient,,,1574.1,944.46,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1101.87,70,,,percent of total billed charges,70% of total billed charges,1180.58,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1259.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1204.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,271.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,708.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1101.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,944.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1101.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,755.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1416.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,246.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,246.66,1762,
NM*GASTRIC EMPTYING STUDY,4218264,CDM,341,RC,78264,HCPCS,Outpatient,,,1464.65,878.79,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1025.26,70,,,percent of total billed charges,70% of total billed charges,1098.49,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1171.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1120.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,659.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1025.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,878.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1025.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,703.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,229.51,1762,
ACUTE GI BLEED STUDY,4218280,CDM,341,RC,78278,HCPCS,Outpatient,,,733.5,440.1,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,513.45,70,,,percent of total billed charges,70% of total billed charges,550.13,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,586.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,561.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,330.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,513.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,513.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,352.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,660.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,114.94,1762,
NM*BOWEL IMAGING MECKELS,4218290,CDM,341,RC,78290,HCPCS,Outpatient,,,1084.05,650.43,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,758.84,70,,,percent of total billed charges,70% of total billed charges,813.04,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,867.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,829.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,186.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,487.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,758.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,650.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,758.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,520.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,975.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,169.87,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,169.87,1762,
LEVEEN/SHUNT PATENCY,4218291,CDM,341,RC,78291,HCPCS,Outpatient,,,516.45,309.87,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,361.52,70,,,percent of total billed charges,70% of total billed charges,387.34,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,413.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,395.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,232.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,361.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,309.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,361.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,247.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,464.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,80.93,1762,
NM*BONE IMAGING LIMITED,4218300,CDM,340,RC,78300,HCPCS,Outpatient,,,1440.45,864.27,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1008.32,70,,,percent of total billed charges,70% of total billed charges,1080.34,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1152.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1101.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,248.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,648.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1008.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,864.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1008.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,691.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,225.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,1762,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",4218306,CDM,341,RC,78306,HCPCS,Outpatient,,,2019.05,1211.43,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1413.34,70,,,percent of total billed charges,70% of total billed charges,1514.29,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1615.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,347.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,908.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1413.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1211.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1413.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,969.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1817.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,316.39,1817.15,
BONE IMAGING 3-PHASE,4218307,CDM,341,RC,78315,HCPCS,Outpatient,,,2245.1,1347.06,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1571.57,70,,,percent of total billed charges,70% of total billed charges,1683.83,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1796.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1717.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,386.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1571.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1347.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1571.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2020.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,351.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,351.81,2020.59,
SPECT-BONE IMAGING,4218320,CDM,341,RC,78803,HCPCS,Outpatient,,,2092.75,1255.65,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1464.93,70,,,percent of total billed charges,70% of total billed charges,1569.56,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1674.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1600.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,360.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,941.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1464.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1255.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1464.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1004.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1883.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,327.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,327.93,4271.43,
MUGA; SGL W WM & EF,4218403,CDM,341,RC,78472,HCPCS,Outpatient,,,1100.55,660.33,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,770.39,70,,,percent of total billed charges,70% of total billed charges,825.41,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,880.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,841.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,495.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,770.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,660.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,770.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,528.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,990.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,172.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,172.46,1762,
NM RADION CHG (CERE TEC),4218404,CDM,343,RC,A9521,HCPCS,Outpatient,,,2580,1548,,464.4,18,,,percent of total billed charges,pays at 18% of total charges,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,464.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1290,50,,,percent of total billed charges,pays at 50% of total billed charges,1806,70,,,percent of total billed charges,70% of total billed charges,1935,75,,,percent of total billed charges,75% of total billed charges,1290,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2064,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1548,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1973.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,444.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1806,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1548,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,980.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1806,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1238.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2580,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2322,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.29,2580,
DX I-131 CAPS PER MCI GNR,4218445,CDM,343,RC,A9528,HCPCS,Outpatient,,,146.3,87.78,,26.33,18,,,percent of total billed charges,pays at 18% of total charges,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.15,50,,,percent of total billed charges,pays at 50% of total billed charges,102.41,70,,,percent of total billed charges,70% of total billed charges,109.73,75,,,percent of total billed charges,75% of total billed charges,73.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,55.59,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,102.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,146.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,131.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.93,146.3,
Image of the heart to assess perfusion,4218482,CDM,341,RC,78452,HCPCS,Outpatient,,,2990.5,1794.3,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2093.35,70,,,percent of total billed charges,70% of total billed charges,2242.88,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2392.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,2287.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,515.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1345.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2093.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1794.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,2093.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2691.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,468.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,468.61,4271.43,
NM*LUNG PERFUSION IMAGING,4218580,CDM,341,RC,78597,HCPCS,Outpatient,,,996,597.6,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,697.2,70,,,percent of total billed charges,70% of total billed charges,747,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,761.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,171.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,697.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,597.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,697.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,478.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,896.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,156.07,1762,
LUNG PERFUSION/VENTILAT,4218582,CDM,341,RC,78582,HCPCS,Outpatient,,,1959.75,1175.85,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1371.83,70,,,percent of total billed charges,70% of total billed charges,1469.81,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1567.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,1499.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,337.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,881.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1371.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1175.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1371.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,940.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1763.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,307.09,1763.78,
NM*LUNG VENTILATION,4218591,CDM,341,RC,78579,HCPCS,Outpatient,,,1000,600,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,700,70,,,percent of total billed charges,70% of total billed charges,750,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,765,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,450,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,480,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,900,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,1762,
LUNG QUANTITATIVE  PERFUSION,4218597,CDM,341,RC,78597,HCPCS,Outpatient,,,1959.75,1175.85,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1371.83,70,,,percent of total billed charges,70% of total billed charges,1469.81,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1567.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1499.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,337.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,881.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1371.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1175.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1371.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,940.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1763.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,307.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,307.09,1763.78,
NM*BRAIN SCAN STATIC COMP,4218605,CDM,341,RC,78606,HCPCS,Outpatient,,,1027.35,616.41,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,719.15,70,,,percent of total billed charges,70% of total billed charges,770.51,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,821.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,785.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,462.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,719.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,616.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,719.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,493.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,924.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,160.99,1762,
NM CSF FLOW CISTEROGRAM,4218630,CDM,340,RC,78630,HCPCS,Outpatient,,,1220,732,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,854,70,,,percent of total billed charges,70% of total billed charges,915,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,976,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,933.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,210.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,549,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,854,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,732,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,854,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,585.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1098,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,191.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,191.17,1762,
DOSE IN-111 DTPA .50 MCI,4218631,CDM,341,RC,A9548,HCPCS,Outpatient,,,1800,1080,,324,18,,,percent of total billed charges,pays at 18% of total charges,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,324,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,900,50,,,percent of total billed charges,pays at 50% of total billed charges,1260,70,,,percent of total billed charges,70% of total billed charges,1350,75,,,percent of total billed charges,75% of total billed charges,900,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1377,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,310.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1762,100,,,Case rate,Pays based on per visit ,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1620,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,282.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.06,1800,
CSF; SHUNT EVAL/PATENCY,4218645,CDM,341,RC,78645,HCPCS,Outpatient,,,490.47,294.28,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,343.33,70,,,percent of total billed charges,70% of total billed charges,367.85,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,392.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,375.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,220.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,343.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,343.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,235.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,441.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,76.86,1762,
NM*CSF LEAK DETECTION,4218650,CDM,341,RC,78650,HCPCS,Outpatient,,,1177,706.2,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1177,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,823.9,70,,,percent of total billed charges,70% of total billed charges,882.75,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,941.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1177,103,,,Fee Schedule,103% of CMS OPPS Rate,900.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,202.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,529.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,823.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,706.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,823.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,564.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1177,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,184.44,4271.43,
RENAL IMAGING STATICS,4218700,CDM,341,RC,78700,HCPCS,Outpatient,,,725,435,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,507.5,70,,,percent of total billed charges,70% of total billed charges,543.75,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,580,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,554.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,124.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,326.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,507.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,435,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,507.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,348,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,652.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,113.61,1762,
DOSE IN-111 WWBC 0.50MCI,4218701,CDM,343,RC,A9570,HCPCS,Outpatient,,,3263.85,1958.31,,587.49,18,,,percent of total billed charges,pays at 18% of total charges,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,587.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1631.93,50,,,percent of total billed charges,pays at 50% of total billed charges,2284.7,70,,,percent of total billed charges,70% of total billed charges,2447.89,75,,,percent of total billed charges,75% of total billed charges,1631.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2611.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1958.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2496.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,562.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1468.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2284.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1958.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1240.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2284.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1566.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3263.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2937.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,511.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.45,3263.85,
RENAL SCAN W/FLO / FUNCTI,4218707,CDM,341,RC,78707,HCPCS,Outpatient,,,1278,766.8,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,894.6,70,,,percent of total billed charges,70% of total billed charges,958.5,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,977.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,575.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,894.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,766.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,894.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,613.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1150.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,200.26,1762,
NM*RENAL SCAN W/ VASOTEC,4218708,CDM,341,RC,78708,HCPCS,Outpatient,,,1893.1,1135.86,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1325.17,70,,,percent of total billed charges,70% of total billed charges,1419.83,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1514.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,1448.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,326.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,851.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1325.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1135.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1325.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,908.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1703.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,296.65,1762,
NM*KIDNEY FUNCT; MULTI,4218709,CDM,341,RC,78709,HCPCS,Outpatient,,,1109,665.4,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,776.3,70,,,percent of total billed charges,70% of total billed charges,831.75,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,887.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,848.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,191.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,499.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,776.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,665.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,776.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,532.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,998.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,173.78,1762,
THYROID UPTAKE (MULTI),4218710,CDM,341,RC,78012,HCPCS,Outpatient,,,636.5,381.9,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,445.55,70,,,percent of total billed charges,70% of total billed charges,477.38,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,509.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,486.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,286.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,445.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,381.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,445.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,305.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,572.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,99.74,1762,
RENAL SCAN W/ LASIX,4218726,CDM,341,RC,78708,HCPCS,Outpatient,,,1893.1,1135.86,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1325.17,70,,,percent of total billed charges,70% of total billed charges,1419.83,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1514.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,1448.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,326.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,851.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1325.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1135.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1325.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,908.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1703.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,296.65,1762,
NM ABSCESS INFECTION INDIUM LIMITED,4218801,CDM,340,RC,78801,HCPCS,Outpatient,,,841,504.6,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,588.7,70,,,percent of total billed charges,70% of total billed charges,630.75,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,672.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,643.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,144.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,378.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,588.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,504.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,588.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,403.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,756.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,131.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,131.78,1762,
NM*TUMOR LOCAL WHOLE BODY,4218802,CDM,340,RC,78802,HCPCS,Outpatient,,,2214.9,1328.94,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1550.43,70,,,percent of total billed charges,70% of total billed charges,1661.18,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1771.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,1694.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,381.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,996.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1550.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1328.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1550.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1993.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,347.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,347.07,4271.43,
SPECT-TUMOR LOCALIZATION,4218803,CDM,340,RC,78803,HCPCS,Outpatient,,,3443,2065.8,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2410.1,70,,,percent of total billed charges,70% of total billed charges,2582.25,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,2633.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,593.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2410.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2065.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,2410.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1652.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3098.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,539.52,4271.43,
WB TUMOR IMAGING 2 DAYS/>,4218804,CDM,340,RC,78804,HCPCS,Outpatient,,,3488,2092.8,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2441.6,70,,,percent of total billed charges,70% of total billed charges,2616,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,2668.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,600.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2092.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,2441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3139.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,546.57,4271.43,
NM*ABSCESS LOCAL LIMITED,4218805,CDM,341,RC,78800,HCPCS,Outpatient,,,1700,1020,,1250.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1190,70,,,percent of total billed charges,70% of total billed charges,1275,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1360,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,1300.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,292.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,765,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1020,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,1190,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,812.69,100,,,Fee Schedule,100% of CMS OPPS Rate,816,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1530,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,266.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,353.35,100,,,Fee Schedule,100% of CMS OPPS Rate,266.39,1762,
NM*ABSCESS LOCAL WHOLEBOD,4218806,CDM,340,RC,78802,HCPCS,Outpatient,,,3443,2065.8,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2410.1,70,,,percent of total billed charges,70% of total billed charges,2582.25,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2754.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,2633.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,593.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2410.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2065.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,2410.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1652.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3098.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,539.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,539.52,4271.43,
NM ABSCESS INFECTION INDIUM WHOLEBODY,4218807,CDM,340,RC,78804,HCPCS,Outpatient,,,3488,2092.8,,4271.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2452.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2441.6,70,,,percent of total billed charges,70% of total billed charges,2616,75,,,percent of total billed charges,75% of total billed charges,2171.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2790.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4223.17,350,,,Fee Schedule,350% of CMS OPPS Rate,1230.74,103,,,Fee Schedule,103% of CMS OPPS Rate,2668.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,600.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2092.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,2441.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2775.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1674.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3139.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,546.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.61,100,,,Fee Schedule,100% of CMS OPPS Rate,546.57,4271.43,
NM RX INJ FOR SURGERY,4218808,CDM,340,RC,78808,HCPCS,Outpatient,,,1000,600,,1250.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,700,70,,,percent of total billed charges,70% of total billed charges,750,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,765,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,172.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,450,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,600,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,700,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,812.7,100,,,Fee Schedule,100% of CMS OPPS Rate,480,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,900,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,156.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,156.7,1762,
SENTINEL NODE INJECTION,4218972,CDM,360,RC,38792,HCPCS,Outpatient,,,996,597.6,,1250.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,353.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,353.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,712.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,697.2,70,,,percent of total billed charges,70% of total billed charges,747,75,,,percent of total billed charges,75% of total billed charges,636.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,796.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1236.72,350,,,Fee Schedule,350% of CMS OPPS Rate,360.41,103,,,Fee Schedule,103% of CMS OPPS Rate,761.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,697.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,597.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,697.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,812.7,100,,,Fee Schedule,100% of CMS OPPS Rate,478.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,896.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,100,,,Fee Schedule,100% of CMS OPPS Rate,353.34,1250.85,
DX-TC 99M SESTAMIBI/DOSE,4218993,CDM,343,RC,A9500,HCPCS,Outpatient,,,481.05,288.63,,86.59,18,,,percent of total billed charges,pays at 18% of total charges,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.53,50,,,percent of total billed charges,pays at 50% of total billed charges,336.74,70,,,percent of total billed charges,70% of total billed charges,360.79,75,,,percent of total billed charges,75% of total billed charges,240.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,182.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,336.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,481.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.38,481.05,
NM*HYPERTHYROIDISM INITIA,4219000,CDM,342,RC,79005,HCPCS,Outpatient,,,648.56,389.14,,803.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,227.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,486.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,453.99,70,,,percent of total billed charges,70% of total billed charges,486.42,75,,,percent of total billed charges,75% of total billed charges,408.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,518.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,794.59,350,,,Fee Schedule,350% of CMS OPPS Rate,231.56,103,,,Fee Schedule,103% of CMS OPPS Rate,496.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,291.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,453.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,389.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,453.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,522.16,100,,,Fee Schedule,100% of CMS OPPS Rate,311.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,583.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,101.63,1762,
TC-99M PERTECHNETATE/MCI,4219037,CDM,343,RC,A9512,HCPCS,Outpatient,,,5.45,3.27,,0.98,18,,,percent of total billed charges,pays at 18% of total charges,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.73,50,,,percent of total billed charges,pays at 50% of total billed charges,3.82,70,,,percent of total billed charges,70% of total billed charges,4.09,75,,,percent of total billed charges,75% of total billed charges,2.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.85,5.45,
NM DOSE CHG I-123,4219040,CDM,343,RC,A9516,HCPCS,Outpatient,,,124.3,74.58,,22.37,18,,,percent of total billed charges,pays at 18% of total charges,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.15,50,,,percent of total billed charges,pays at 50% of total billed charges,87.01,70,,,percent of total billed charges,70% of total billed charges,93.23,75,,,percent of total billed charges,75% of total billed charges,62.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,95.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,124.3,
NM DOSE CHG XE133 10 MCI,4219046,CDM,343,RC,A9558,HCPCS,Outpatient,,,124,74.4,,22.32,18,,,percent of total billed charges,pays at 18% of total charges,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62,50,,,percent of total billed charges,pays at 50% of total billed charges,86.8,70,,,percent of total billed charges,70% of total billed charges,93,75,,,percent of total billed charges,75% of total billed charges,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.43,124,
GA 67 PER MCI,4219047,CDM,343,RC,A9556,HCPCS,Outpatient,,,78.3,46.98,,14.09,18,,,percent of total billed charges,pays at 18% of total charges,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.15,50,,,percent of total billed charges,pays at 50% of total billed charges,54.81,70,,,percent of total billed charges,70% of total billed charges,58.73,75,,,percent of total billed charges,75% of total billed charges,39.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,62.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,54.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,70.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,78.3,
NM SINCALIDE INJ KINEVAC,4219051,CDM,636,RC,J2805,HCPCS,Outpatient,,,159.5,95.7,,28.71,18,,,percent of total billed charges,pays at 18% of total charges,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.75,50,,,percent of total billed charges,pays at 50% of total billed charges,111.65,70,,,percent of total billed charges,70% of total billed charges,119.63,75,,,percent of total billed charges,75% of total billed charges,79.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,127.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,159.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,143.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,159.5,
NM DOSE CHC DMSA,4219052,CDM,343,RC,A9551,HCPCS,Outpatient,,,567,340.2,,102.06,18,,,percent of total billed charges,pays at 18% of total charges,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,283.5,50,,,percent of total billed charges,pays at 50% of total billed charges,396.9,70,,,percent of total billed charges,70% of total billed charges,425.25,75,,,percent of total billed charges,75% of total billed charges,283.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,433.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,97.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,396.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,567,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,510.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.85,567,
TC99M MEBROFENIN TO 15MCI,4219053,CDM,343,RC,A9537,HCPCS,Outpatient,,,61.05,36.63,,10.99,18,,,percent of total billed charges,pays at 18% of total charges,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.53,50,,,percent of total billed charges,pays at 50% of total billed charges,42.74,70,,,percent of total billed charges,70% of total billed charges,45.79,75,,,percent of total billed charges,75% of total billed charges,30.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,54.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.57,61.05,
TC99M MAA,4219056,CDM,343,RC,A9540,HCPCS,Outpatient,,,326,195.6,,58.68,18,,,percent of total billed charges,pays at 18% of total charges,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.68,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163,50,,,percent of total billed charges,pays at 50% of total billed charges,228.2,70,,,percent of total billed charges,70% of total billed charges,244.5,75,,,percent of total billed charges,75% of total billed charges,163,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,249.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,228.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,293.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.08,326,
TC99M SULFUR COLLOID PER STUDY,4219057,CDM,343,RC,A9541,HCPCS,Outpatient,,,448.8,269.28,,80.78,18,,,percent of total billed charges,pays at 18% of total charges,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,224.4,50,,,percent of total billed charges,pays at 50% of total billed charges,314.16,70,,,percent of total billed charges,70% of total billed charges,336.6,75,,,percent of total billed charges,75% of total billed charges,224.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,359.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,269.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,343.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,77.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,314.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,269.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,448.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,403.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,70.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.33,448.8,
TC99M LABELED RBC,4219058,CDM,343,RC,A9560,HCPCS,Outpatient,,,415.8,249.48,,74.84,18,,,percent of total billed charges,pays at 18% of total charges,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,207.9,50,,,percent of total billed charges,pays at 50% of total billed charges,291.06,70,,,percent of total billed charges,70% of total billed charges,311.85,75,,,percent of total billed charges,75% of total billed charges,207.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,332.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,249.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,415.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,374.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.16,415.8,
TC99M MERTIATIDE MAG3,4219059,CDM,343,RC,A9562,HCPCS,Outpatient,,,848.1,508.86,,152.66,18,,,percent of total billed charges,pays at 18% of total charges,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,152.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,424.05,50,,,percent of total billed charges,pays at 50% of total billed charges,593.67,70,,,percent of total billed charges,70% of total billed charges,636.08,75,,,percent of total billed charges,75% of total billed charges,424.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,678.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,648.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,146.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,593.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,508.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,593.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,848.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,763.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.9,848.1,
IN111 PENTETREOTIDE/MCI,4219060,CDM,343,RC,A9572,HCPCS,Outpatient,,,5422,3253.2,,975.96,18,,,percent of total billed charges,pays at 18% of total charges,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,975.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2711,50,,,percent of total billed charges,pays at 50% of total billed charges,3795.4,70,,,percent of total billed charges,70% of total billed charges,4066.5,75,,,percent of total billed charges,75% of total billed charges,2711,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4337.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3253.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4147.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,934.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2439.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3795.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3253.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3795.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2602.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5422,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4879.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,849.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.63,5422,
TL201 THALLIUM,4219500,CDM,343,RC,A9505,HCPCS,Outpatient,,,481,288.6,,86.58,18,,,percent of total billed charges,pays at 18% of total charges,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.5,50,,,percent of total billed charges,pays at 50% of total billed charges,336.7,70,,,percent of total billed charges,70% of total billed charges,360.75,75,,,percent of total billed charges,75% of total billed charges,240.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,481,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,75.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.37,481,
NM*TC MDP 30 MCI,4219503,CDM,343,RC,A9503,HCPCS,Outpatient,,,146.85,88.11,,26.43,18,,,percent of total billed charges,pays at 18% of total charges,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,73.43,50,,,percent of total billed charges,pays at 50% of total billed charges,102.8,70,,,percent of total billed charges,70% of total billed charges,110.14,75,,,percent of total billed charges,75% of total billed charges,73.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,117.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,88.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,146.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,132.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,146.85,
NM DOSE I-131 TX PER MCI,4219504,CDM,344,RC,A9517,HCPCS,Outpatient,,,146.3,87.78,,84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,23.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.15,50,,,percent of total billed charges,pays at 50% of total billed charges,102.41,70,,,percent of total billed charges,70% of total billed charges,109.73,75,,,percent of total billed charges,75% of total billed charges,42.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,117.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.05,350,,,Fee Schedule,350% of CMS OPPS Rate,24.2,103,,,Fee Schedule,103% of CMS OPPS Rate,111.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,102.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,54.57,100,,,Fee Schedule,100% of CMS OPPS Rate,70.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,131.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,131.67,
CSF ;SHUNT EVAL/PATENCY,4219529,CDM,341,RC,78645,HCPCS,Outpatient,,,1278,766.8,,1623.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,458.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,923.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,894.6,70,,,percent of total billed charges,70% of total billed charges,958.5,75,,,percent of total billed charges,75% of total billed charges,825.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1022.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1605.24,350,,,Fee Schedule,350% of CMS OPPS Rate,467.81,103,,,Fee Schedule,103% of CMS OPPS Rate,977.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,575.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,894.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,766.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,894.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.86,100,,,Fee Schedule,100% of CMS OPPS Rate,613.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1150.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,458.64,100,,,Fee Schedule,100% of CMS OPPS Rate,200.26,1762,
TC99M PENTETATE,4219539,CDM,343,RC,A9539,HCPCS,Outpatient,,,140.36,84.22,,25.26,18,,,percent of total billed charges,pays at 18% of total charges,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.18,50,,,percent of total billed charges,pays at 50% of total billed charges,98.25,70,,,percent of total billed charges,70% of total billed charges,105.27,75,,,percent of total billed charges,75% of total billed charges,70.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,126.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,140.36,
NM CERETEC WBC,4219569,CDM,343,RC,A9569,HCPCS,Outpatient,,,2580,1548,,464.4,18,,,percent of total billed charges,pays at 18% of total charges,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,464.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1290,50,,,percent of total billed charges,pays at 50% of total billed charges,1806,70,,,percent of total billed charges,70% of total billed charges,1935,75,,,percent of total billed charges,75% of total billed charges,1290,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2064,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1548,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1973.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,444.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1806,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1548,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1806,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1238.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2580,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2322,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,404.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.29,2580,
NM DOSE I-131 F/U DOSE,4219898,CDM,344,RC,C9898,HCPCS,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.18,1,
TC-99M NONENRICHED ADD-ON,4219969,CDM,343,RC,C9898,HCPCS,Outpatient,,,1,0.6,,0.18,18,,,percent of total billed charges,pays at 18% of total charges,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.7,70,,,percent of total billed charges,70% of total billed charges,0.75,75,,,percent of total billed charges,75% of total billed charges,0.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,0.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,1,
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,4220038,CDM,360,RC,64483,HCPCS,Outpatient,,,1200,720,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,2742.49,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",4220061,CDM,350,RC,10160,HCPCS,Outpatient,,,865,519,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,865,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,605.5,70,,,percent of total billed charges,70% of total billed charges,648.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,692,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,661.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,389.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,519,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,415.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,778.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,865,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,1709,
CALCIUM SCORING,4220144,CDM,350,RC,75571,HCPCS,Outpatient,,,555.84,333.5,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,389.09,70,,,percent of total billed charges,70% of total billed charges,416.88,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,444.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,425.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,250.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,389.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,333.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,389.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,266.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,500.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,1709,
CT CALCIUM SCORING,4220145,CDM,350,RC,75571,HCPCS,Outpatient,,,216,129.6,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,151.2,70,,,percent of total billed charges,70% of total billed charges,162,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,1709,
CTA CORONARY W/O SCORE,4220146,CDM,350,RC,75574,HCPCS,Outpatient,,,785.4,471.24,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,549.78,70,,,percent of total billed charges,70% of total billed charges,589.05,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,628.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,600.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,353.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,471.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,376.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,706.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,123.07,1709,
CTA CORONARY ARTERIES,4220147,CDM,350,RC,75574,HCPCS,Outpatient,,,785.4,471.24,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,549.78,70,,,percent of total billed charges,70% of total billed charges,589.05,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,628.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,600.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,353.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,471.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,376.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,706.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,123.07,1709,
CT SACROPLASTY INJ UNILAT,422020,CDM,360,RC,0200T,HCPCS,Outpatient,,,14184,8510.4,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9928.8,70,,,percent of total billed charges,70% of total billed charges,10638,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10850.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6382.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8510.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6808.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12765.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,21287.29,
"KIDNEY BX, BY TROCAR PERC",4220200,CDM,360,RC,50200,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
CT SACROPLASTY INJ BILAT,4220201,CDM,360,RC,0201T,HCPCS,Outpatient,,,6400,3840,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4480,70,,,percent of total billed charges,70% of total billed charges,4800,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,4896,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,3072,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5760,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,21287.29,
BX TRAY,4220201E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CT SACROPLASTY INJ BILAT,4220201E,CDM,360,RC,0201T,HCPCS,Outpatient,,,6400,3840,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4480,70,,,percent of total billed charges,70% of total billed charges,4800,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,4896,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3840,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4480,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,3072,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5760,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,21287.29,
TRAY BALLON SACROPLASTY,4220201E,CDM,272,RC,,,Outpatient,,,5021,3012.6,,903.78,18,,,percent of total billed charges,pays at 18% of total charges,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2510.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3514.7,70,,,percent of total billed charges,70% of total billed charges,3765.75,75,,,percent of total billed charges,75% of total billed charges,2510.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4016.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3841.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2259.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2410.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5021,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4518.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.79,5021,
SACROPLASTY BONE CEMENT,4220201E,CDM,278,RC,,,Outpatient,,,318,190.8,,57.24,18,,,percent of total billed charges,pays at 18% of total charges,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159,50,,,percent of total billed charges,pays at 50% of total billed charges,222.6,70,,,percent of total billed charges,70% of total billed charges,238.5,75,,,percent of total billed charges,75% of total billed charges,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.83,318,
BX TRAY,4220202E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
TRAY BALLON SACROPLASTY,4220202E,CDM,272,RC,,,Outpatient,,,5021,3012.6,,903.78,18,,,percent of total billed charges,pays at 18% of total charges,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2510.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3514.7,70,,,percent of total billed charges,70% of total billed charges,3765.75,75,,,percent of total billed charges,75% of total billed charges,2510.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4016.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3841.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2259.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1907.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2410.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5021,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4518.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.79,5021,
SACROPLASTY BONE CEMENT,4220202E,CDM,278,RC,,,Outpatient,,,318,190.8,,57.24,18,,,percent of total billed charges,pays at 18% of total charges,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159,50,,,percent of total billed charges,pays at 50% of total billed charges,222.6,70,,,percent of total billed charges,70% of total billed charges,238.5,75,,,percent of total billed charges,75% of total billed charges,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.83,318,
CT SACROPLASTY INJ UNILAT,4220202E,CDM,360,RC,0200T,HCPCS,Outpatient,,,14184,8510.4,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9928.8,70,,,percent of total billed charges,70% of total billed charges,10638,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10850.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6382.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8510.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6808.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12765.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,21287.29,
MUSCLE BX PERC NDL,4220206,CDM,360,RC,20206,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
BONE BX SUPERFCL TROCAR OR NDL,4220220,CDM,360,RC,20220,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2748.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4825.85,
BONE BX DEEP TROCAR OR NDL,4220225,CDM,360,RC,20225,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
CT scan head or brain without dye,4220450,CDM,351,RC,70450,HCPCS,Outpatient,,,2102.98,1261.79,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1472.09,70,,,percent of total billed charges,70% of total billed charges,1577.24,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1682.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1608.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,362.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,946.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1261.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1472.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,329.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1892.68,
CT Scan of the face and jaw without dye,4220451,CDM,351,RC,70486,HCPCS,Outpatient,,,2018.89,1211.33,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1413.22,70,,,percent of total billed charges,70% of total billed charges,1514.17,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1615.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,347.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,908.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1211.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,969.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1817,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1817,
CT Scan of the face and jaw without dye,4220453,CDM,351,RC,70486,HCPCS,Outpatient,,,2018.89,1211.33,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1413.22,70,,,percent of total billed charges,70% of total billed charges,1514.17,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1615.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,347.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,908.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1211.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,969.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1817,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1817,
CT HEAD/BRAIN W CONTRAST,4220460,CDM,351,RC,70460,HCPCS,Outpatient,,,1318.19,790.91,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,922.73,70,,,percent of total billed charges,70% of total billed charges,988.64,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1054.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1008.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,227.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,593.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,922.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,790.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,922.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,632.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,206.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT HEAD/BRAIN W/WO CONT,4220470,CDM,351,RC,70470,HCPCS,Outpatient,,,2881.62,1728.97,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2017.13,70,,,percent of total billed charges,70% of total billed charges,2161.22,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2305.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,2204.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,496.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2017.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1728.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,2017.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1383.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2593.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2593.46,
CT IAC/SELLA/ORBIT W/O,4220480,CDM,351,RC,70480,HCPCS,Outpatient,,,2018.89,1211.33,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1413.22,70,,,percent of total billed charges,70% of total billed charges,1514.17,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1615.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,347.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,908.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1211.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,969.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1817,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1817,
CT IAC/SELLA/ORBIT W/CONT,4220481,CDM,351,RC,70481,HCPCS,Outpatient,,,2220.96,1332.58,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1554.67,70,,,percent of total billed charges,70% of total billed charges,1665.72,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1776.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1699.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,382.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,999.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1554.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1332.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1554.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1998.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,348.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1998.86,
CT IAC/SELLA/ORBIT W/WO,4220482,CDM,351,RC,70482,HCPCS,Outpatient,,,1518.55,911.13,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1062.99,70,,,percent of total billed charges,70% of total billed charges,1138.91,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1214.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1161.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,261.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,683.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1062.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,911.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1062.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,728.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1366.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,237.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT - MF W CONTR,4220487,CDM,351,RC,70487,HCPCS,Outpatient,,,2018.89,1211.33,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1413.22,70,,,percent of total billed charges,70% of total billed charges,1514.17,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1615.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,347.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,908.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1211.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,969.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1817,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1817,
CT - MF W&WO CONTR,4220488,CDM,351,RC,70488,HCPCS,Outpatient,,,2018.89,1211.33,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1413.22,70,,,percent of total billed charges,70% of total billed charges,1514.17,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1615.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1544.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,347.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,908.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1211.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1413.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,969.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1817,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1817,
CT NECK SOFT TISSUE W/O C,4220490,CDM,351,RC,70490,HCPCS,Outpatient,,,2302.03,1381.22,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1611.42,70,,,percent of total billed charges,70% of total billed charges,1726.52,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1841.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1761.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,396.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1035.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1611.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1381.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1611.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,2071.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,2071.83,
CT scan of neck with dye,4220491,CDM,351,RC,70491,HCPCS,Outpatient,,,2591.82,1555.09,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1814.27,70,,,percent of total billed charges,70% of total billed charges,1943.87,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2073.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1982.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,446.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1814.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1555.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1814.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2332.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,406.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2332.64,
CT NECK SOFT TISSUE W/WO CONT,4220492,CDM,351,RC,70492,HCPCS,Outpatient,,,2750,1650,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1925,70,,,percent of total billed charges,70% of total billed charges,2062.5,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,2103.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,473.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1237.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1925,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1650,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1925,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1320,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2475,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,430.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2475,
CTA HEAD,4220496,CDM,351,RC,70496,HCPCS,Outpatient,,,1837.94,1102.76,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1286.56,70,,,percent of total billed charges,70% of total billed charges,1378.46,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1470.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1406.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,316.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,827.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1286.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1102.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1286.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,882.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1654.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,288.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CTA NECK,4220498,CDM,350,RC,70498,HCPCS,Outpatient,,,2021.31,1212.79,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1414.92,70,,,percent of total billed charges,70% of total billed charges,1515.98,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1617.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1546.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,348.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,909.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1414.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1212.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1414.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,970.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,316.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1819.18,
CT RF ABLATION RENAL,4220592,CDM,360,RC,50592,HCPCS,Outpatient,,,8000,4800,,16773.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8602.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges,6000,75,,,percent of total billed charges,75% of total billed charges,8529.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16584.27,350,,,Fee Schedule,350% of CMS OPPS Rate,4833.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10898.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7200,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,16773.81,
CT GUIDED CRYO ABLATION RENAL,4220593,CDM,761,RC,50593,HCPCS,Outpatient,,,20165,12099,,29244.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8261.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8261.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15486.3,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,15123.75,75,,,percent of total billed charges,75% of total billed charges,14870.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,16132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28914.41,350,,,Fee Schedule,350% of CMS OPPS Rate,8426.48,103,,,Fee Schedule,103% of CMS OPPS Rate,15426.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3474.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9074.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,14115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12099,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7662.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,14115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,19000.9,100,,,Fee Schedule,100% of CMS OPPS Rate,9679.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,18148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3159.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8261.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3159.86,29244.87,
Draining or injecting medication into a small joint/bursa without ultrasound,4220600,CDM,360,RC,20600,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a large joint/bursa without ultrasound,4220605,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a major joint/bursa without ultrasound,4220610,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
CT scan of the thorax without dye,4221250,CDM,352,RC,71250,HCPCS,Outpatient,,,2127.02,1276.21,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1488.91,70,,,percent of total billed charges,70% of total billed charges,1595.27,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1701.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1627.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,366.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,957.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1488.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1276.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1488.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1914.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1914.32,
CT scan of the thorax with dye,4221260,CDM,352,RC,71260,HCPCS,Outpatient,,,2822.93,1693.76,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1976.05,70,,,percent of total billed charges,70% of total billed charges,2117.2,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2258.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,2159.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,486.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1976.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1693.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1976.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1355.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2540.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,442.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2540.64,
CT THORAX; W/WO CONTRAS,4221270,CDM,352,RC,71270,HCPCS,Outpatient,,,3125.43,1875.26,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2187.8,70,,,percent of total billed charges,70% of total billed charges,2344.07,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2500.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,2390.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,538.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1406.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2187.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1875.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,2187.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1500.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2812.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,489.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2812.89,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,4221275,CDM,352,RC,71275,HCPCS,Outpatient,,,2612.42,1567.45,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1828.69,70,,,percent of total billed charges,70% of total billed charges,1959.32,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2089.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1998.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,450.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1828.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1567.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1828.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1253.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2351.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,409.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2351.18,
CT CERVICAL W/O CONTRAST,4222125,CDM,352,RC,72125,HCPCS,Outpatient,,,2881.62,1728.97,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2017.13,70,,,percent of total billed charges,70% of total billed charges,2161.22,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2305.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,2204.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,496.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2017.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1728.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,2017.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1383.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,2593.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,2593.46,
CT CERVICAL W/ CONTRAST,4222126,CDM,352,RC,72126,HCPCS,Outpatient,,,2095.72,1257.43,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1467,70,,,percent of total billed charges,70% of total billed charges,1571.79,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1676.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,943.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1467,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1257.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1467,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1005.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1886.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,328.4,1886.15,
CT CERVICAL W/WO CONTRAST,4222127,CDM,352,RC,72127,HCPCS,Outpatient,,,1905.2,1143.12,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1333.64,70,,,percent of total billed charges,70% of total billed charges,1428.9,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1524.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1457.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,328.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,857.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,914.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1714.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1714.68,
CT THORACIC W/O CONTRAST,4222128,CDM,352,RC,72128,HCPCS,Outpatient,,,2095.72,1257.43,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1467,70,,,percent of total billed charges,70% of total billed charges,1571.79,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1676.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,943.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1467,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1257.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1467,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1005.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1886.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1886.15,
CT THORACIC W/ CONTRAST,4222129,CDM,352,RC,72129,HCPCS,Outpatient,,,1714.68,1028.81,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1200.28,70,,,percent of total billed charges,70% of total billed charges,1286.01,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1371.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1311.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,295.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,771.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1200.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1028.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1200.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,823.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1543.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,268.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT THORACIC SPINE W/WO,4222130,CDM,350,RC,72130,HCPCS,Outpatient,,,1905.2,1143.12,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1333.64,70,,,percent of total billed charges,70% of total billed charges,1428.9,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1524.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1457.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,328.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,857.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,914.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1714.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1714.68,
CT scan of lower spine without dye,4222131,CDM,352,RC,72131,HCPCS,Outpatient,,,2136.2,1281.72,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1495.34,70,,,percent of total billed charges,70% of total billed charges,1602.15,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1708.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1634.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,368.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,961.29,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1495.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1281.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1495.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1922.58,
CT LUMBAR W/CONTRAST,4222132,CDM,352,RC,72132,HCPCS,Outpatient,,,1791.68,1075.01,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1254.18,70,,,percent of total billed charges,70% of total billed charges,1343.76,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1433.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1370.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,308.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,806.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1254.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1075.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1254.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,860.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1612.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,280.76,1709,
CT LUMBAR W/WO CONTRAST,4222133,CDM,352,RC,72133,HCPCS,Outpatient,,,1465.92,879.55,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1026.14,70,,,percent of total billed charges,70% of total billed charges,1099.44,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1172.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1121.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,659.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1026.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,879.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1026.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,703.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1319.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,229.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CTA PELVIS,4222191,CDM,352,RC,72191,HCPCS,Outpatient,,,1674,1004.4,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1171.8,70,,,percent of total billed charges,70% of total billed charges,1255.5,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1280.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,753.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1171.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1171.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,803.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1506.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT of pelvis without dye,4222192,CDM,352,RC,72192,HCPCS,Outpatient,,,1546.92,928.15,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1082.84,70,,,percent of total billed charges,70% of total billed charges,1160.19,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1237.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1183.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,266.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,696.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1082.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,928.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1082.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,742.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1392.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,242.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1709,
"CT scan, pelvis, with contrast",4222193,CDM,352,RC,72193,HCPCS,Outpatient,,,2036.32,1221.79,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1425.42,70,,,percent of total billed charges,70% of total billed charges,1527.24,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1629.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1557.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,350.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,916.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1425.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1221.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1425.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,977.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1832.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,319.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1832.69,
"CT,PELVIS; W/WO CONTRAS",4222195,CDM,352,RC,72194,HCPCS,Outpatient,,,2381.28,1428.77,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1666.9,70,,,percent of total billed charges,70% of total billed charges,1785.96,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1905.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1821.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,410.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1666.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1428.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1666.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2143.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2143.15,
INTERDISCAL PERC ASPR DX,4222267,CDM,360,RC,62267,HCPCS,Outpatient,,,500,300,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,500,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,350,70,,,percent of total billed charges,70% of total billed charges,375,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,500,103,,,Fee Schedule,103% of CMS OPPS Rate,382.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,225,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,350,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,240,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,500,100,,,Fee Schedule,100% of CMS OPPS Rate,450,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,225,2088.52,
CT VERTEBROPLASTY LUMB,4222292,CDM,350,RC,22511,HCPCS,Outpatient,,,4240,2544,,9579.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4240,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5285.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2968,70,,,percent of total billed charges,70% of total billed charges,3180,75,,,percent of total billed charges,75% of total billed charges,4870.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9471.28,350,,,Fee Schedule,350% of CMS OPPS Rate,2760.2,103,,,Fee Schedule,103% of CMS OPPS Rate,3243.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2544,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2035.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3816,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,9579.52,
LUNG BX SITE CHARGE,4222405,CDM,360,RC,32408,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1857.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
BIOPSY NEEDLES,4222405E,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
BX TRAY,4222405E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
LUNG BX SITE CHARGE,4222405E,CDM,360,RC,32408,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1857.5,50,,,percent of total billed charges,pays at 50% of total billed charges,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
CT THORACIC KYPHOPLASTY,4222513,CDM,350,RC,22513,HCPCS,Outpatient,,,13007,7804.2,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13007,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11202.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,21287.29,
CT LUMBAR KYPHOPLASTY,4222514,CDM,350,RC,22514,HCPCS,Outpatient,,,13007,7804.2,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13007,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11202.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13007,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,21287.29,
CT  KYPHOPLASTY ADD LEVEL,4222515,CDM,350,RC,22515,HCPCS,Outpatient,,,13007,7804.2,,2341.26,18,,,percent of total billed charges,pays at 18% of total charges,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2341.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,6503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2241.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13007,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2038.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709,13007,
CT VERTEBROPLASTY LUMB,4222521,CDM,350,RC,22511,HCPCS,Outpatient,,,4240,2544,,9579.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4240,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5285.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2968,70,,,percent of total billed charges,70% of total billed charges,3180,75,,,percent of total billed charges,75% of total billed charges,4870.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9471.28,350,,,Fee Schedule,350% of CMS OPPS Rate,2760.2,103,,,Fee Schedule,103% of CMS OPPS Rate,3243.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2544,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2035.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3816,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,9579.52,
BX TRAY,4222521E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CT VERTEBROPLASTY LUMB,4222521E,CDM,350,RC,22511,HCPCS,Outpatient,,,4240,2544,,9579.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4240,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5285.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2968,70,,,percent of total billed charges,70% of total billed charges,3180,75,,,percent of total billed charges,75% of total billed charges,4870.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9471.28,350,,,Fee Schedule,350% of CMS OPPS Rate,2760.2,103,,,Fee Schedule,103% of CMS OPPS Rate,3243.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2544,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2035.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3816,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,9579.52,
CT VERTEBROPLASTY LUMB ADDT LEVEL,4222522,CDM,350,RC,22512,HCPCS,Outpatient,,,3200,1920,,576,18,,,percent of total billed charges,pays at 18% of total charges,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,576,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,1600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,551.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2880,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.44,3200,
CT GUIDED FIDUCIAL MARKER PLACEMENT THOR,4222553,CDM,490,RC,32553,HCPCS,Outpatient,,,1534.4,920.64,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,359.35,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping Rate,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1074.08,70,,,percent of total billed charges,70% of total billed charges,1150.8,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1227.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1173.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1074.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,920.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1074.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,736.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,359.35,4314.56,
CRYOABLATION NEEDLE,4222618,CDM,272,RC,C2618,HCPCS,Outpatient,,,2463.5,1478.1,,443.43,18,,,percent of total billed charges,pays at 18% of total charges,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,443.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1724.45,70,,,percent of total billed charges,70% of total billed charges,1847.63,75,,,percent of total billed charges,75% of total billed charges,1231.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1970.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1478.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1884.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,424.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1724.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1478.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,936.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1724.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1182.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2463.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2217.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,386.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.03,2463.5,
CT;U EXTR WO CONTRAST LEFT,4223200,CDM,352,RC,73200,HCPCS,Outpatient,,,1674.2,1004.52,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1171.94,70,,,percent of total billed charges,70% of total billed charges,1255.65,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1339.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1280.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,753.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,803.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1506.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1709,
CT;U EXTR WO CONTRAST RIGHT,4223200RT,CDM,352,RC,73200,HCPCS,Outpatient,,,1674.2,1004.52,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1171.94,70,,,percent of total billed charges,70% of total billed charges,1255.65,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1339.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1280.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,753.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,803.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1506.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1709,
CT UPPER EXTREMITY W/CONT LEFT,4223201,CDM,352,RC,73201,HCPCS,Outpatient,,,1905.2,1143.12,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1333.64,70,,,percent of total billed charges,70% of total billed charges,1428.9,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1524.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1457.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,328.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,857.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,914.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1714.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,298.54,1714.68,
CT UPPER EXTREMITY W/CONT RIGHT,4223201RT,CDM,352,RC,73201,HCPCS,Outpatient,,,1905.2,1143.12,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1333.64,70,,,percent of total billed charges,70% of total billed charges,1428.9,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1524.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,1457.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,328.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,857.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1143.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1333.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,914.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1714.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,298.54,1714.68,
CT UPPER EXTREMITY W/WOCONT LEFT,4223202,CDM,352,RC,73202,HCPCS,Outpatient,,,2000,1200,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1800,
CT UPPER EXTREMITY W/WOCONT RIGHT,4223202RT,CDM,352,RC,73202,HCPCS,Outpatient,,,2000,1200,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1800,
CTA UPPER EXTREMITY LEFT,4223206,CDM,350,RC,73206,HCPCS,Outpatient,,,1754,1052.4,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1227.8,70,,,percent of total billed charges,70% of total billed charges,1315.5,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,302.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,789.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1227.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1052.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1227.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,841.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CTA UPPER EXTREMITY RIGHT,4223206RT,CDM,350,RC,73206,HCPCS,Outpatient,,,1754,1052.4,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1227.8,70,,,percent of total billed charges,70% of total billed charges,1315.5,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,302.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,789.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1227.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1052.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1227.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,841.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT scan of leg without dye,4223700,CDM,352,RC,73700,HCPCS,Outpatient,,,1674.2,1004.52,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1171.94,70,,,percent of total billed charges,70% of total billed charges,1255.65,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1339.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1280.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,753.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,803.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1506.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1709,
CT scan of leg without dye,4223700RT,CDM,352,RC,73700,HCPCS,Outpatient,,,1674.2,1004.52,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1171.94,70,,,percent of total billed charges,70% of total billed charges,1255.65,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1339.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1280.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,753.39,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1171.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,803.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1506.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1709,
"CT, L EXTR W CONTRAST LEFT",4223701,CDM,352,RC,73701,HCPCS,Outpatient,,,1640.32,984.19,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1148.22,70,,,percent of total billed charges,70% of total billed charges,1230.24,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1312.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1254.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,282.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,738.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1148.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1148.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,787.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
"CT, L EXTR W CONTRAST RIGHT",4223701RT,CDM,352,RC,73701,HCPCS,Outpatient,,,1640.32,984.19,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1148.22,70,,,percent of total billed charges,70% of total billed charges,1230.24,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1312.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1254.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,282.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,738.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1148.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1148.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,787.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT LOW EXT W/WO CONTRAST LEFT,4223702,CDM,352,RC,73702,HCPCS,Outpatient,,,1676.58,1005.95,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1173.61,70,,,percent of total billed charges,70% of total billed charges,1257.44,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1341.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1282.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,288.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,754.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1173.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1005.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1173.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,804.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1508.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT LOW EXT W/WO CONTRAST RIGHT,4223702RT,CDM,352,RC,73702,HCPCS,Outpatient,,,1750,1050,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1225,70,,,percent of total billed charges,70% of total billed charges,1312.5,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1338.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,301.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,787.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1225,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1050,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1225,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1575,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CTA LOWER EXTREMITY,4223706,CDM,350,RC,73706,HCPCS,Outpatient,,,1754,1052.4,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1227.8,70,,,percent of total billed charges,70% of total billed charges,1315.5,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1403.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1341.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,302.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,789.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1227.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1052.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1227.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,841.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,274.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1709,
CT of abdomen without dye,4224150,CDM,352,RC,74150,HCPCS,Outpatient,,,1889.8,1133.88,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1322.86,70,,,percent of total billed charges,70% of total billed charges,1417.35,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1511.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1445.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,325.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,850.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1322.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1133.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1322.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,907.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1700.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1709,
CT of abdomen with dye,4224160,CDM,352,RC,74160,HCPCS,Outpatient,,,2095.72,1257.43,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1467,70,,,percent of total billed charges,70% of total billed charges,1571.79,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1676.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1603.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,943.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1467,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1257.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1467,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1005.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1886.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,1886.15,
CT of abdomen with and without dye,4224170,CDM,352,RC,74170,HCPCS,Outpatient,,,2386.56,1431.94,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1670.59,70,,,percent of total billed charges,70% of total billed charges,1789.92,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1909.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1825.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,411.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1670.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1431.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1670.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1145.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2147.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,373.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2147.9,
CTA ABDOMEN AND PELVIS,4224174,CDM,352,RC,74174,HCPCS,Outpatient,,,2800,1680,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1960,70,,,percent of total billed charges,70% of total billed charges,2100,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,2142,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,482.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1260,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1344,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2520,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,438.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,2520,
CTA ABDOMEN,4224175,CDM,352,RC,74175,HCPCS,Outpatient,,,2337.72,1402.63,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1636.4,70,,,percent of total billed charges,70% of total billed charges,1753.29,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1870.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1788.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,402.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1636.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1402.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1636.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1122.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2103.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,366.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2103.95,
CT of abdomen and pelvis without dye,4224176,CDM,352,RC,74176,HCPCS,Outpatient,,,4840,2904,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3388,70,,,percent of total billed charges,70% of total billed charges,3630,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,3702.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,833.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2178,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2904,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,3388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2323.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4356,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,4356,
CT scan of abdomen and pelvis with contrast,4224177,CDM,352,RC,74177,HCPCS,Outpatient,,,4840,2904,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3388,70,,,percent of total billed charges,70% of total billed charges,3630,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,3702.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,833.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2178,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2904,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,3388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2323.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,4356,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,4356,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",4224178,CDM,352,RC,74178,HCPCS,Outpatient,,,4840,2904,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3388,70,,,percent of total billed charges,70% of total billed charges,3630,75,,,percent of total billed charges,75% of total billed charges,602.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3872,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,3702.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,833.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2178,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2904,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,3388,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,770.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2323.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,4356,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,758.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.94,4356,
CT PUDENDAL NERVE INJ,4224430,CDM,352,RC,64430,HCPCS,Outpatient,,,1398,838.8,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1398,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,978.6,70,,,percent of total billed charges,70% of total billed charges,1048.5,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1118.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,1069.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,629.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,978.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,838.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,978.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,671.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1258.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1398,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,629.1,2742.49,
INJ ANESTH CELIAC PLEXUS,4224531,CDM,322,RC,64530,HCPCS,Outpatient,,,990,594,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,693,70,,,percent of total billed charges,70% of total billed charges,742.5,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,757.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,445.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,693,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,594,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,693,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,475.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,891,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,364,2742.49,
CT HEART WITH 3D IMAGING,4225572,CDM,350,RC,75572,HCPCS,Outpatient,,,785.4,471.24,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,549.78,70,,,percent of total billed charges,70% of total billed charges,589.05,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,628.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,600.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,353.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,471.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,376.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,706.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,123.07,1709,
CT HEART CONGENITAL ABNORMALITY,4225573,CDM,350,RC,75573,HCPCS,Outpatient,,,785.4,471.24,,580.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,549.78,70,,,percent of total billed charges,70% of total billed charges,589.05,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,628.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.8,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,600.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,353.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,471.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,549.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,376.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,706.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,123.07,1709,
CTA ABD AOR/BIL/ART,4225635,CDM,352,RC,75635,HCPCS,Outpatient,,,2346.96,1408.18,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1642.87,70,,,percent of total billed charges,70% of total billed charges,1760.22,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1877.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,1795.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,404.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1056.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1642.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1408.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1642.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2112.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,367.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,2112.26,
CT RAD GUIDANCE ABCESS DRAIN,4225989,CDM,350,RC,75989,HCPCS,Outpatient,,,435.6,261.36,,78.41,18,,,percent of total billed charges,pays at 18% of total charges,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.92,70,,,percent of total billed charges,70% of total billed charges,326.7,75,,,percent of total billed charges,75% of total billed charges,217.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,348.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,435.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,392.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,68.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.26,1709,
CT GUIDED NDL PLACEMENT,4226360,CDM,350,RC,77012,HCPCS,Outpatient,,,1560.68,936.41,,280.92,18,,,percent of total billed charges,pays at 18% of total charges,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.48,70,,,percent of total billed charges,70% of total billed charges,1170.51,75,,,percent of total billed charges,75% of total billed charges,780.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.56,1709,
BIOPSY NEEDLES,4226360E,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
BX TRAY,4226360E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CT GUIDED NDL PLACEMENT,4226360E,CDM,350,RC,77012,HCPCS,Outpatient,,,1560.68,936.41,,280.92,18,,,percent of total billed charges,pays at 18% of total charges,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.48,70,,,percent of total billed charges,70% of total billed charges,1170.51,75,,,percent of total billed charges,75% of total billed charges,780.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.56,1709,
CT PLACEM RAD THERAP FLD,4226370,CDM,350,RC,77014,HCPCS,Outpatient,,,1521.3,912.78,,273.83,18,,,percent of total billed charges,pays at 18% of total charges,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,273.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.91,70,,,percent of total billed charges,70% of total billed charges,1140.98,75,,,percent of total billed charges,75% of total billed charges,760.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1217.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,912.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1163.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,262.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1064.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,912.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,1064.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1521.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1369.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.39,1709,
CT LIMITED OR FOLLOW UP,4226380,CDM,359,RC,76380,HCPCS,Outpatient,,,564.3,338.58,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,395.01,70,,,percent of total billed charges,70% of total billed charges,423.23,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,451.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,431.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,97.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,395.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,338.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,395.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,270.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,507.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,1709,
NEEDLE BX LIVER PERCUTAN,4227000,CDM,360,RC,47000,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
CT GUIDED RF ABLATION,4227013,CDM,350,RC,77013,HCPCS,Outpatient,,,1560.68,936.41,,280.92,18,,,percent of total billed charges,pays at 18% of total charges,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.48,70,,,percent of total billed charges,70% of total billed charges,1170.51,75,,,percent of total billed charges,75% of total billed charges,780.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.56,1709,
BX TRAY,4227013E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CT GUIDED RF ABLATION,4227013E,CDM,350,RC,77013,HCPCS,Outpatient,,,1560.68,936.41,,280.92,18,,,percent of total billed charges,pays at 18% of total charges,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.48,70,,,percent of total billed charges,70% of total billed charges,1170.51,75,,,percent of total billed charges,75% of total billed charges,780.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.56,1709,
CT RF ABLATION RENAL,4227013E,CDM,360,RC,50592,HCPCS,Outpatient,,,8000,4800,,16773.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8602.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges,6000,75,,,percent of total billed charges,75% of total billed charges,8529.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16584.27,350,,,Fee Schedule,350% of CMS OPPS Rate,4833.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10898.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7200,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,16773.81,
"KIDNEY BX, BY TROCAR PERC",4227013E,CDM,360,RC,50200,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
CT JOINT SURVEY SINGLE VIEW,4227077,CDM,352,RC,77077,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,1709,
SIJ INJ ARTHROGR/ANESTH,4227096,CDM,360,RC,27096,HCPCS,Outpatient,,,1002,601.2,,180.36,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,180.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,701.4,70,,,percent of total billed charges,70% of total billed charges,751.5,75,,,percent of total billed charges,75% of total billed charges,501,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,801.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,601.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,766.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,701.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,601.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,701.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1002,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,901.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.36,1107.9,
CT RF ABLATION LIVER,4227382,CDM,360,RC,47382,HCPCS,Outpatient,,,8000,4800,,16773.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8968.94,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges,6000,75,,,percent of total billed charges,75% of total billed charges,8529.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16584.27,350,,,Fee Schedule,350% of CMS OPPS Rate,4833.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10898.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7200,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,16773.81,
BX TRAY,4227382E,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CT GUIDED RF ABLATION,4227382E,CDM,350,RC,77013,HCPCS,Outpatient,,,1560.68,936.41,,280.92,18,,,percent of total billed charges,pays at 18% of total charges,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,280.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.48,70,,,percent of total billed charges,70% of total billed charges,1170.51,75,,,percent of total billed charges,75% of total billed charges,780.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1248.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1193.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,936.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,1092.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1560.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1404.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,244.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.56,1709,
CT RF ABLATION LIVER,4227382E,CDM,360,RC,47382,HCPCS,Outpatient,,,8000,4800,,16773.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8968.94,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges,6000,75,,,percent of total billed charges,75% of total billed charges,8529.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6400,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16584.27,350,,,Fee Schedule,350% of CMS OPPS Rate,4833.13,103,,,Fee Schedule,103% of CMS OPPS Rate,6120,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4800,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5600,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10898.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3840,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,7200,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,16773.81,
BX PANCREAS PER NEEDLE,4228102,CDM,360,RC,48102,HCPCS,Outpatient,,,631.6,378.96,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,631.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2748.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,442.12,70,,,percent of total billed charges,70% of total billed charges,473.7,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,505.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,631.6,103,,,Fee Schedule,103% of CMS OPPS Rate,483.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,284.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,442.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,442.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,303.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,631.6,100,,,Fee Schedule,100% of CMS OPPS Rate,568.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,284.22,4825.85,
LYMPH NODE,4228505,CDM,360,RC,,,Outpatient,,,756,453.6,,136.08,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,136.08,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,378,50,,,percent of total billed charges,pays at 50% of total billed charges,529.2,70,,,percent of total billed charges,70% of total billed charges,567,75,,,percent of total billed charges,75% of total billed charges,378,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,604.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,453.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,578.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,529.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,453.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,287.28,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,529.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,756,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,680.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.08,756,
3D RECONSTR OF CT OR MRI,4228838,CDM,350,RC,76376,HCPCS,Outpatient,,,874.5,524.7,,157.41,18,,,percent of total billed charges,pays at 18% of total charges,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,157.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.15,70,,,percent of total billed charges,70% of total billed charges,655.88,75,,,percent of total billed charges,75% of total billed charges,437.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,699.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,668.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,150.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,612.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,524.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,612.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,874.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,787.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.03,1709,
3D RECONST W WORKSTATION,4228839,CDM,350,RC,76377,HCPCS,Outpatient,,,715.5,429.3,,128.79,18,,,percent of total billed charges,pays at 18% of total charges,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.79,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.85,70,,,percent of total billed charges,70% of total billed charges,536.63,75,,,percent of total billed charges,75% of total billed charges,357.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,572.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,429.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,547.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,500.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,429.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1709,100,,,Case rate,Pays based on per visit ,500.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,715.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,643.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.12,1709,
CT PERITONEAL DRAINAGE (PERC,4229021,CDM,360,RC,49406,HCPCS,Outpatient,,,1600,960,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,4825.85,
"INJ,ANESTH;CELIAC PLEXUS",422-9088,CDM,322,RC,64530,HCPCS,Outpatient,,,990,594,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,693,70,,,percent of total billed charges,70% of total billed charges,742.5,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,792,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,757.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,445.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,693,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,594,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,693,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,475.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,891,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,364,2742.49,
CT-SYMPATHETIC NERVE BLOC,4229089,CDM,320,RC,64520,HCPCS,Outpatient,,,813.6,488.16,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,813.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,569.52,70,,,percent of total billed charges,70% of total billed charges,610.2,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,650.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,622.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,366.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,569.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,569.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,390.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,732.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,813.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,364,2742.49,
PERC N BX ABD/RETROPERITO,4229180,CDM,360,RC,49180,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
BX TRAY,4229254,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CT GUIDED ABCESS DRAIN,4229406,CDM,350,RC,49406,HCPCS,Outpatient,,,5208,3124.8,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3645.6,70,,,percent of total billed charges,70% of total billed charges,3906,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3984.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,897.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2343.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3645.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,3645.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2499.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,4687.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,816.09,4825.85,
DRAIN POUCH NBPS-100,4229406E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
NEEDLE-PERCUT-195326,4229406E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
GUIDEWIRES,4229406E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
FLEXIMA NEPHROSTOMY CATH,4229406E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
CT GUIDED ABCESS DRAIN,4229406E,CDM,350,RC,49406,HCPCS,Outpatient,,,5208,3124.8,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3645.6,70,,,percent of total billed charges,70% of total billed charges,3906,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4166.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3984.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,897.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2343.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3645.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3124.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,3645.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2499.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,4687.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,816.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,816.09,4825.85,
CT GUIDED FUIDICIAL MARKER PLACE ABDOMEN,4229411,CDM,490,RC,49411,HCPCS,Outpatient,,,1534,920.4,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,359.35,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping Rate,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1073.8,70,,,percent of total billed charges,70% of total billed charges,1150.5,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1227.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1173.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1073.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,920.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1073.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,736.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,359.35,4314.56,
CT LOW DOSE LUNG,422LUNG,CDM,352,RC,71271,HCPCS,Outpatient,,,2127,1276.2,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1063.5,50,,,percent of total billed charges,pays at 50% of total billed charges,1488.9,70,,,percent of total billed charges,70% of total billed charges,1595.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1701.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,1627.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,366.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,957.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1488.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1276.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1709,100,,,Case rate,Pays based on per visit ,1488.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1914.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,333.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,1914.3,
BX CLIP,4230003,CDM,278,RC,A4648,HCPCS,Outpatient,,,149.4,89.64,,26.89,18,,,percent of total billed charges,pays at 18% of total charges,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.58,70,,,percent of total billed charges,70% of total billed charges,112.05,75,,,percent of total billed charges,75% of total billed charges,74.7,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,149.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.41,149.4,
"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",4230022,CDM,402,RC,10005,HCPCS,Outpatient,,,713.6,428.16,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1181.22,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,499.52,70,,,percent of total billed charges,70% of total billed charges,535.2,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,570.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,545.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,122.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,321.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,499.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,342.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,642.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,111.82,2088.52,
INC & DRNG ABSCESS CMPLCTD OR MULTI,4230061,CDM,402,RC,10061,HCPCS,Outpatient,,,514.8,308.88,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,514.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,360.36,70,,,percent of total billed charges,70% of total billed charges,386.1,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,411.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,393.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,231.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,360.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,308.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,360.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,463.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,514.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,231.66,1200.6,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",4230160,CDM,402,RC,10160,HCPCS,Outpatient,,,502.7,301.62,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,502.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,351.89,70,,,percent of total billed charges,70% of total billed charges,377.03,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,402.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,384.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,226.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,301.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,351.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,241.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,452.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,502.7,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,226.22,1200.6,
MUSCLE BX PERC NDL,4230206,CDM,402,RC,20206,HCPCS,Outpatient,,,840,504,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,840,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,840,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,588,70,,,percent of total billed charges,70% of total billed charges,630,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,840,103,,,Fee Schedule,103% of CMS OPPS Rate,642.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,378,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,504,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,403.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,840,100,,,Fee Schedule,100% of CMS OPPS Rate,756,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,840,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,378,4825.85,
US AAA SCREENING,4230389,CDM,402,RC,G0389,HCPCS,Outpatient,,,200,120,,36,18,,,percent of total billed charges,pays at 18% of total charges,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100,50,,,percent of total billed charges,pays at 50% of total billed charges,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,446,
ARTHROCENTESIS MJT W/US,4230611,CDM,402,RC,20611,HCPCS,Outpatient,,,717,430.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,717,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,501.9,70,,,percent of total billed charges,70% of total billed charges,537.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,548.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,322.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,344.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,645.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,717,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",4231100,CDM,402,RC,10005,HCPCS,Outpatient,,,260.01,156.01,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,260.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1181.22,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,182.01,70,,,percent of total billed charges,70% of total billed charges,195.01,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,260.01,103,,,Fee Schedule,103% of CMS OPPS Rate,198.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,117,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,182.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,124.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,260.01,100,,,Fee Schedule,100% of CMS OPPS Rate,234.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,40.74,2088.52,
THORACENTSIS INCISI,4232000,CDM,402,RC,32555,HCPCS,Outpatient,,,344.4,206.64,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,344.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,241.08,70,,,percent of total billed charges,70% of total billed charges,258.3,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,275.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,344.4,103,,,Fee Schedule,103% of CMS OPPS Rate,263.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,154.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,241.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,241.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,165.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,344.4,100,,,Fee Schedule,100% of CMS OPPS Rate,309.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,344.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,154.98,1861.73,
Study of vessels on both sides of the head and neck,4233870,CDM,921,RC,93880,HCPCS,Outpatient,,,689.4,413.64,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,482.58,70,,,percent of total billed charges,70% of total billed charges,517.05,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,551.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,527.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,310.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,482.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,413.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,482.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,330.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,620.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,108.03,751.51,
US EXT LOW ARTERIAL BILAT,4233925,CDM,921,RC,93925,HCPCS,Outpatient,,,754.16,452.5,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,527.91,70,,,percent of total billed charges,70% of total billed charges,565.62,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,603.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,576.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,129.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,339.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,527.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,452.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,527.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,362,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,678.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,118.18,751.51,
US EXT LOWER ART/UNILAT LEFT,4233926,CDM,921,RC,93926,HCPCS,Outpatient,,,474.8,284.88,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,332.36,70,,,percent of total billed charges,70% of total billed charges,356.1,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,379.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,363.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,213.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,227.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,427.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,427.32,
US EXT LOWER ART/UNILAT RIGHT,4233926RT,CDM,921,RC,93926,HCPCS,Outpatient,,,474.8,284.88,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,332.36,70,,,percent of total billed charges,70% of total billed charges,356.1,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,379.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,363.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,213.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,284.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,332.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,227.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,427.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.4,427.32,
US EXT UP ARTERIAL BILAT,4233930,CDM,921,RC,93930,HCPCS,Outpatient,,,685.6,411.36,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.92,70,,,percent of total billed charges,70% of total billed charges,514.2,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,524.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,308.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,479.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,329.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,617.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,107.43,751.51,
US EXT UPPER ART/UNILAT LEFT,4233931,CDM,921,RC,93931,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
US EXT UPPER ART/UNILAT RIGHT,4233931RT,CDM,921,RC,93931,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
Complete bilateral study of the extremities,4233950,CDM,921,RC,93970,HCPCS,Outpatient,,,734.04,440.42,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,513.83,70,,,percent of total billed charges,70% of total billed charges,550.53,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,587.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,561.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,330.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,513.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,513.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,352.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,660.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,115.02,751.51,
Complete bilateral study of the extremities,4233970,CDM,921,RC,93970,HCPCS,Outpatient,,,734.04,440.42,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,513.83,70,,,percent of total billed charges,70% of total billed charges,550.53,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,587.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,561.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,330.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,513.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,440.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,513.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,352.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,660.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,115.02,751.51,
One sided or limited bilateral study,4233972,CDM,921,RC,93971,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
One sided or limited bilateral study,4233972RT,CDM,921,RC,93971,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
One sided or limited bilateral study,4233973,CDM,921,RC,93971,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
One sided or limited bilateral study,4233973RT,CDM,921,RC,93971,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
US DOPPLER ABD/RETROPER,4233976,CDM,921,RC,93976,HCPCS,Outpatient,,,522.28,313.37,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,365.6,70,,,percent of total billed charges,70% of total billed charges,391.71,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,417.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,399.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,89.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,235.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,313.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,365.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,250.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.84,470.05,
"ECHO, B-SCAN W A MODE",4236506,CDM,402,RC,76506,HCPCS,Outpatient,,,526.5,315.9,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,368.55,70,,,percent of total billed charges,70% of total billed charges,394.88,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,421.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,402.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,236.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,368.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,368.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,252.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,473.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,82.5,473.85,
Ultrasound of head and neck,4236536,CDM,402,RC,76536,HCPCS,Outpatient,,,572,343.2,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,400.4,70,,,percent of total billed charges,70% of total billed charges,429,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,457.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,437.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,257.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,400.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,400.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,274.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,514.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.63,514.8,
B-SCAN CHEST US,4236604,CDM,402,RC,76604,HCPCS,Outpatient,,,491.4,294.84,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,343.98,70,,,percent of total billed charges,70% of total billed charges,368.55,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,393.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,375.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,221.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,343.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,294.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,343.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,235.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,442.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,77,446,
US BREAST UNILAT COMPLETE LT,4236641,CDM,402,RC,76641,HCPCS,Outpatient,,,415.8,249.48,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,291.06,70,,,percent of total billed charges,70% of total billed charges,311.85,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,332.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,318.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,187.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,199.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,374.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.16,446,
Limited ultrasound of the breast,4236642,CDM,402,RC,76642,HCPCS,Outpatient,,,415.8,249.48,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,291.06,70,,,percent of total billed charges,70% of total billed charges,311.85,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,332.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,318.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,187.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,199.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,374.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,65.16,446,
Ultrasound of abdomen with all areas scanned,4236700,CDM,402,RC,76700,HCPCS,Outpatient,,,903.27,541.96,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,632.29,70,,,percent of total billed charges,70% of total billed charges,677.45,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,722.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,691,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,155.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,406.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,632.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,541.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,632.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,433.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,812.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,141.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,812.94,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,4236705,CDM,402,RC,76705,HCPCS,Outpatient,,,307.34,184.4,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,215.14,70,,,percent of total billed charges,70% of total billed charges,230.51,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,235.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,138.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,147.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,276.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,446,
US ABD AAA SCREEN,4236706,CDM,402,RC,76706,HCPCS,Outpatient,,,303,181.8,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
Ultrasound of back wall of the abdomen with all areas viewed,4236770,CDM,402,RC,76770,HCPCS,Outpatient,,,647.96,388.78,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,453.57,70,,,percent of total billed charges,70% of total billed charges,485.97,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,518.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,495.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,291.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,453.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,388.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,453.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,311.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,583.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,583.16,
Ultrasound of back wall of the abdomen with limited areas viewed,4236775,CDM,402,RC,76775,HCPCS,Outpatient,,,572,343.2,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,400.4,70,,,percent of total billed charges,70% of total billed charges,429,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,457.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,437.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,257.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,400.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,400.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,274.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,514.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,89.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.63,514.8,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,4236801,CDM,402,RC,76801,HCPCS,Outpatient,,,414.9,248.94,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,290.43,70,,,percent of total billed charges,70% of total billed charges,311.18,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,331.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,317.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,186.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,290.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,199.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,373.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.01,446,
US OB <14 WKS/ADD FETUS,4236802,CDM,402,RC,76802,HCPCS,Outpatient,,,290.25,174.15,,52.25,18,,,percent of total billed charges,pays at 18% of total charges,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.18,70,,,percent of total billed charges,70% of total billed charges,217.69,75,,,percent of total billed charges,75% of total billed charges,145.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,203.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,290.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,261.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.48,446,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,4236807,CDM,402,RC,76805,HCPCS,Outpatient,,,559.35,335.61,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,391.55,70,,,percent of total billed charges,70% of total billed charges,419.51,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,447.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,427.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,96.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,251.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,391.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,335.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,391.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,268.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,503.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,87.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,87.65,503.42,
US OB >14 WKS/ADD FETUS,4236808,CDM,402,RC,76810,HCPCS,Outpatient,,,397.08,238.25,,71.47,18,,,percent of total billed charges,pays at 18% of total charges,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,71.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.96,70,,,percent of total billed charges,70% of total billed charges,297.81,75,,,percent of total billed charges,75% of total billed charges,198.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,317.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,238.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,303.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,277.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,397.08,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,357.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.22,446,
Ultrasound of fetus with limited views,4236815,CDM,402,RC,76815,HCPCS,Outpatient,,,311.4,186.84,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,217.98,70,,,percent of total billed charges,70% of total billed charges,233.55,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,249.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,238.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,217.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,149.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,280.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.8,446,
OB US FOLLOW-UP PER FETUS,4236816,CDM,402,RC,76816,HCPCS,Outpatient,,,271.44,162.86,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,190.01,70,,,percent of total billed charges,70% of total billed charges,203.58,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,217.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,207.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,122.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,190.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,130.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,244.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,446,
Transvaginal ultrasound of uterus,4236817,CDM,402,RC,76817,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
Fetal biophysical profile without non-stress test,4236819,CDM,402,RC,76819,HCPCS,Outpatient,,,322.92,193.75,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,226.04,70,,,percent of total billed charges,70% of total billed charges,242.19,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,258.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,247.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,145.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,226.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,155,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,290.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,50.6,446,
UMBILICAL ARTERY ECHO,4236821,CDM,402,RC,76820,HCPCS,Outpatient,,,553.52,332.11,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,387.46,70,,,percent of total billed charges,70% of total billed charges,415.14,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,442.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,423.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,249.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,387.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,387.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,265.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,498.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,86.74,498.17,
Ultrasound of the pelvis through vagina,4236830,CDM,402,RC,76830,HCPCS,Outpatient,,,397.21,238.33,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,278.05,70,,,percent of total billed charges,70% of total billed charges,297.91,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,303.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,178.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,278.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,190.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,357.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.24,446,
Complete ultrasound of the pelvis,4236856,CDM,402,RC,76856,HCPCS,Outpatient,,,770.39,462.23,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,539.27,70,,,percent of total billed charges,70% of total billed charges,577.79,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,616.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,589.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,132.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,346.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,539.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,462.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,539.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,369.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,693.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,120.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,693.35,
Limited ultrasound of the pelvis,4236857,CDM,402,RC,76857,HCPCS,Outpatient,,,398.2,238.92,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,278.74,70,,,percent of total billed charges,70% of total billed charges,298.65,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,318.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,304.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,179.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,278.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,191.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,358.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.4,446,
Transrectal ultrasound,4236872,CDM,402,RC,76872,HCPCS,Outpatient,,,440.88,264.53,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,308.62,70,,,percent of total billed charges,70% of total billed charges,330.66,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,352.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,337.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,75.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,198.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,308.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,264.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,308.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,211.62,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,396.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,69.09,446,
US EXTREMITY NON-VASCULAR LT,4236881,CDM,402,RC,76881,HCPCS,Outpatient,,,425.92,255.55,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,298.14,70,,,percent of total billed charges,70% of total billed charges,319.44,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,340.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,325.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,298.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,298.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,204.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,383.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,446,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",4236882,CDM,402,RC,76882,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
US GUIDED NEEDLE PLACMNT LEFT,4236942,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
US GUIDED NEEDLE PLACMT RIGHT,4236942RT,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
US GUIDED NEEDLE PLACMNT LEFT,4236942TL,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
US GUIDED NEEDLE PLACMT RIGHT,4236942TR,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
LIVER BX PERC NDL,4237000,CDM,402,RC,47000,HCPCS,Outpatient,,,568.8,341.28,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,568.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,568.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,398.16,70,,,percent of total billed charges,70% of total billed charges,426.6,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,455.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,568.8,103,,,Fee Schedule,103% of CMS OPPS Rate,435.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,255.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,398.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,341.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,398.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,273.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,568.8,100,,,Fee Schedule,100% of CMS OPPS Rate,511.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,568.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,255.96,4825.85,
LYMPH NODE,4238505,CDM,402,RC,38505,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3715,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,4825.85,
US PORTABLE,4238888,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Removal of amniotic fluid from the uterus for diagnostic purposes,4239000,CDM,402,RC,59000,HCPCS,Outpatient,,,310.65,186.39,,2263.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,310.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,310.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1173.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,217.46,70,,,percent of total billed charges,70% of total billed charges,232.99,75,,,percent of total billed charges,75% of total billed charges,1151.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,248.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2238.33,350,,,Fee Schedule,350% of CMS OPPS Rate,310.65,103,,,Fee Schedule,103% of CMS OPPS Rate,237.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,139.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,217.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1470.9,100,,,Fee Schedule,100% of CMS OPPS Rate,149.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,310.65,100,,,Fee Schedule,100% of CMS OPPS Rate,279.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,139.79,2263.91,
US GUIDED CYST ASPIRATION LT,4239001,CDM,402,RC,19000,HCPCS,Outpatient,,,1651,990.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1651,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1155.7,70,,,percent of total billed charges,70% of total billed charges,1238.25,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1320.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1263.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,742.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,792.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,446,2088.52,
US GUIDED CYST ASP EACH ADDITIONAL  LT,4239002,CDM,402,RC,19001,HCPCS,Outpatient,,,240,144,,43.2,18,,,percent of total billed charges,pays at 18% of total charges,240,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,43.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,70,,,percent of total billed charges,70% of total billed charges,180,75,,,percent of total billed charges,75% of total billed charges,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,216,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,446,
PERITONEOCENTESIS;INITIAL,4239080,CDM,360,RC,49083,HCPCS,Outpatient,,,484.51,290.71,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,484.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,339.16,70,,,percent of total billed charges,70% of total billed charges,363.38,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,387.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,484.51,103,,,Fee Schedule,103% of CMS OPPS Rate,370.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,218.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,339.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,290.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,339.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,232.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,484.51,100,,,Fee Schedule,100% of CMS OPPS Rate,436.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,218.03,2656.66,
US GUIDED BREAST BX W/ CLIP LT,4239083L,CDM,402,RC,19083,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3715,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,4825.85,
US GUIDED BREAST BX W/ CLIP RT,4239083R,CDM,402,RC,19083,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3715,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,4825.85,
US GUIDED BREAST BX W CLIP ADD LES LT,4239084L,CDM,402,RC,19084,HCPCS,Outpatient,,,871.2,522.72,,156.82,18,,,percent of total billed charges,pays at 18% of total charges,871.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,156.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.84,70,,,percent of total billed charges,70% of total billed charges,653.4,75,,,percent of total billed charges,75% of total billed charges,435.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,696.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,522.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,609.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,522.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,609.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,871.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,784.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.82,871.2,
US GUIDED BREAST BX W CLIP ADD LES RT,4239084R,CDM,402,RC,19084,HCPCS,Outpatient,,,871.2,522.72,,156.82,18,,,percent of total billed charges,pays at 18% of total charges,871.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,156.82,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.84,70,,,percent of total billed charges,70% of total billed charges,653.4,75,,,percent of total billed charges,75% of total billed charges,435.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,696.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,522.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,666.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,609.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,522.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,609.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,871.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,784.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,871.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.82,871.2,
PERC NDL BRST BX WO GUID,4239100,CDM,402,RC,19100,HCPCS,Outpatient,,,476,285.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,476,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,476,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2583.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,333.2,70,,,percent of total billed charges,70% of total billed charges,357,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,380.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,476,103,,,Fee Schedule,103% of CMS OPPS Rate,364.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,214.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,333.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,285.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,333.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,228.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,476,100,,,Fee Schedule,100% of CMS OPPS Rate,428.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,476,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,214.2,4825.85,
REMOVAL OF BREAST LESION,4239120,CDM,360,RC,19120,HCPCS,Outpatient,,,5467,3280.2,,11063.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5450.55,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3826.9,70,,,percent of total billed charges,70% of total billed charges,4100.25,75,,,percent of total billed charges,75% of total billed charges,5625.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10938.56,350,,,Fee Schedule,350% of CMS OPPS Rate,3187.8,103,,,Fee Schedule,103% of CMS OPPS Rate,4182.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2460.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3826.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3280.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3826.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2624.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4920.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,11063.57,
RETROPERITONEAL,4239180,CDM,320,RC,49180,HCPCS,Outpatient,,,894,536.4,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,894,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,894,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,625.8,70,,,percent of total billed charges,70% of total billed charges,670.5,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,715.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,894,103,,,Fee Schedule,103% of CMS OPPS Rate,683.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,402.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,625.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,536.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,625.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,429.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,894,100,,,Fee Schedule,100% of CMS OPPS Rate,804.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,894,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,4825.85,
BX TRAY,4239254,CDM,270,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
WIRE LOCALIZATION US GUIDE LT,4239290LT,CDM,761,RC,19285,HCPCS,Outpatient,,,1651,990.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1651,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1238.25,75,,,percent of total billed charges,75% of total billed charges,1061.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1320.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1263.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,742.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,627.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,792.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,2088.52,
WIRE LOCALIZATION US GUIDE RT,4239290RT,CDM,761,RC,19285,HCPCS,Outpatient,,,1651,990.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1651,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1238.25,75,,,percent of total billed charges,75% of total billed charges,1061.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1320.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1263.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,742.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,627.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,792.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,2088.52,
WIRE LOCALIZATION ADDITIONAL MASS,4239291,CDM,320,RC,19286,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,364,
WIRE LOCALIZATION ADDITIONAL MASS LT,4239291LT,CDM,320,RC,19286,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,364,
WIRE LOCALIZATION ADDITIONAL MASS RT,4239291RT,CDM,320,RC,19286,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,364,
MAG SEED,4239292,CDM,278,RC,A4648,HCPCS,Outpatient,,,643.5,386.1,,115.83,18,,,percent of total billed charges,pays at 18% of total charges,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,115.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.45,70,,,percent of total billed charges,70% of total billed charges,482.63,75,,,percent of total billed charges,75% of total billed charges,321.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,514.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,643.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,386.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,450.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,643.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,643.5,
TISSUE MARKER PLACEMENT,4239295,CDM,320,RC,10035,HCPCS,Outpatient,,,148.72,89.23,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,148.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,104.1,70,,,percent of total billed charges,70% of total billed charges,111.54,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,118.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,148.72,103,,,Fee Schedule,103% of CMS OPPS Rate,113.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,66.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,104.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,71.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,148.72,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,23.3,2088.52,
SIMULATION SIMPLE,4250001,CDM,333,RC,77280,HCPCS,Outpatient,,,661.75,397.05,,429.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,463.23,70,,,percent of total billed charges,70% of total billed charges,496.31,75,,,percent of total billed charges,75% of total billed charges,218.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,529.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.39,350,,,Fee Schedule,350% of CMS OPPS Rate,123.67,103,,,Fee Schedule,103% of CMS OPPS Rate,506.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,297.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,463.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,278.88,100,,,Fee Schedule,100% of CMS OPPS Rate,317.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,595.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,103.7,705,
SIMULATION INTERMEDIATE,4250002,CDM,333,RC,77285,HCPCS,Outpatient,,,907,544.2,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,693.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,816.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,142.13,1154.43,
SIMULATION COMPLEX,4250003,CDM,333,RC,77290,HCPCS,Outpatient,,,1279.51,767.71,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,895.66,70,,,percent of total billed charges,70% of total billed charges,959.63,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1023.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,978.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,575.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,895.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,767.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,895.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,614.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,200.5,1154.43,
THER RAD PORT FILM,4250004,CDM,333,RC,77417,HCPCS,Outpatient,,,229.5,137.7,,41.31,18,,,percent of total billed charges,pays at 18% of total charges,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.65,70,,,percent of total billed charges,70% of total billed charges,172.13,75,,,percent of total billed charges,75% of total billed charges,114.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705,100,,,Case rate,Pays based on per visit ,160.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.96,705,
CT SCAN FOR THERAPY GUIDE,4250007,CDM,333,RC,77014,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705,705,
CENTRAL AXIS DOSE CALCULA,4250100,CDM,333,RC,77300,HCPCS,Outpatient,,,371.13,222.68,,429.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,259.79,70,,,percent of total billed charges,70% of total billed charges,278.35,75,,,percent of total billed charges,75% of total billed charges,218.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,296.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.39,350,,,Fee Schedule,350% of CMS OPPS Rate,123.67,103,,,Fee Schedule,103% of CMS OPPS Rate,283.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,167.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,259.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,278.88,100,,,Fee Schedule,100% of CMS OPPS Rate,178.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,334.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,58.16,705,
TELETHERAPY ISODOSE SIMPL,4250101,CDM,333,RC,77306,HCPCS,Outpatient,,,907,544.2,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,693.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,816.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,142.13,1154.43,
TELETHERAPY ISODOSE COMPX,4250103,CDM,333,RC,77307,HCPCS,Outpatient,,,907,544.2,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,693.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,816.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,142.13,1154.43,
BRACHYTHERAPY ISODOSE SIMPL,4250105,CDM,333,RC,77316,HCPCS,Outpatient,,,907,544.2,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,693.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,816.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,142.13,1154.43,
BRACHYTHERAPY ISODOSE INT,4250106,CDM,333,RC,77317,HCPCS,Outpatient,,,793,475.8,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,555.1,70,,,percent of total billed charges,70% of total billed charges,594.75,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,634.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,606.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,136.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,356.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,555.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,475.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,555.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,380.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,713.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,124.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,124.26,1154.43,
BRACHYTHERAPY ISODOSE COM,4250107,CDM,333,RC,77318,HCPCS,Outpatient,,,907,544.2,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,693.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,816.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,142.13,1154.43,
RESP MOTION MANGMNT,4250110,CDM,333,RC,77293,HCPCS,Outpatient,,,319,191.4,,57.42,18,,,percent of total billed charges,pays at 18% of total charges,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.3,70,,,percent of total billed charges,70% of total billed charges,239.25,75,,,percent of total billed charges,75% of total billed charges,159.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,223.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705,100,,,Case rate,Pays based on per visit ,223.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,319,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,287.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.99,705,
SPECIAL DOSIMETRY MICRO,4250111,CDM,333,RC,77331,HCPCS,Outpatient,,,286.2,171.72,,429.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,200.34,70,,,percent of total billed charges,70% of total billed charges,214.65,75,,,percent of total billed charges,75% of total billed charges,218.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,228.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.39,350,,,Fee Schedule,350% of CMS OPPS Rate,123.67,103,,,Fee Schedule,103% of CMS OPPS Rate,218.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,128.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,200.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,278.88,100,,,Fee Schedule,100% of CMS OPPS Rate,137.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,257.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.85,705,
TRMT DEVICE DES/CONST SIM,4250112,CDM,333,RC,77332,HCPCS,Outpatient,,,546.25,327.75,,429.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,382.38,70,,,percent of total billed charges,70% of total billed charges,409.69,75,,,percent of total billed charges,75% of total billed charges,218.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,437,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.39,350,,,Fee Schedule,350% of CMS OPPS Rate,123.67,103,,,Fee Schedule,103% of CMS OPPS Rate,417.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,94.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,245.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,382.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,327.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,382.38,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,278.88,100,,,Fee Schedule,100% of CMS OPPS Rate,262.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,491.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,85.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,85.6,705,
TX DEVICES; COMPLEX,4250114,CDM,333,RC,77334,HCPCS,Outpatient,,,907,544.2,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,634.9,70,,,percent of total billed charges,70% of total billed charges,680.25,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,725.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,693.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,156.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,408.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,544.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,634.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,816.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,142.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,142.13,1154.43,
RADIATION PHYSICS CONSUL,4250115,CDM,333,RC,77336,HCPCS,Outpatient,,,422.17,253.3,,429.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,295.52,70,,,percent of total billed charges,70% of total billed charges,316.63,75,,,percent of total billed charges,75% of total billed charges,218.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,337.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.39,350,,,Fee Schedule,350% of CMS OPPS Rate,123.67,103,,,Fee Schedule,103% of CMS OPPS Rate,322.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,189.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,295.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,295.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,278.88,100,,,Fee Schedule,100% of CMS OPPS Rate,202.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,379.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,66.15,705,
3D ISODOSE PLAN,4250116,CDM,333,RC,77295,HCPCS,Outpatient,,,3606.45,2163.87,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2524.52,70,,,percent of total billed charges,70% of total billed charges,2704.84,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2885.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,2758.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,621.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1622.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2524.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2163.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,2524.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3245.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,565.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,565.13,4314.56,
LINEAR ACCL SRS TX 1 SESSN,4250173,CDM,333,RC,77372,HCPCS,Outpatient,,,8715,5229,,24749.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6991.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6991.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15117.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,6100.5,70,,,percent of total billed charges,70% of total billed charges,6536.25,75,,,percent of total billed charges,75% of total billed charges,12584.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24470.23,350,,,Fee Schedule,350% of CMS OPPS Rate,7131.32,103,,,Fee Schedule,103% of CMS OPPS Rate,6666.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1501.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,3921.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6100.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1876,100,,,Case rate,Pays based on per visit ,6100.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,16080.44,100,,,Fee Schedule,100% of CMS OPPS Rate,4183.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7843.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1365.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,6991.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1365.64,24749.89,
"LINEAR ACCL SBRT TX, MAX 5 FRACTNS",4250251,CDM,333,RC,77373,HCPCS,Outpatient,,,4787,2872.2,,5688.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1606.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1606.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3419.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3350.9,70,,,percent of total billed charges,70% of total billed charges,3590.25,75,,,percent of total billed charges,75% of total billed charges,2892.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3829.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5623.75,350,,,Fee Schedule,350% of CMS OPPS Rate,1638.91,103,,,Fee Schedule,103% of CMS OPPS Rate,3662.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,824.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,2154.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3350.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2872.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,381,100,,,Case rate,Pays based on per visit ,3350.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,3695.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2297.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,4308.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1606.78,100,,,Fee Schedule,100% of CMS OPPS Rate,381,5688.02,
INTERST RS APPL; COMPLEX,4250308,CDM,333,RC,77778,HCPCS,Outpatient,,,2764.3,1658.58,,2322.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,656.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1456,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1935.01,70,,,percent of total billed charges,70% of total billed charges,2073.23,75,,,percent of total billed charges,75% of total billed charges,1181,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2211.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2296.4,350,,,Fee Schedule,350% of CMS OPPS Rate,669.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2114.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,476.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1243.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1935.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1658.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,1935.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1326.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,433.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,433.17,2487.87,
BT SOURCE NONSTRD HDR IRIDIUM 192,4250322,CDM,278,RC,C1717,HCPCS,Outpatient,,,681,408.6,,1188.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,335.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,340.5,50,,,percent of total billed charges,pays at 50% of total billed charges,476.7,70,,,percent of total billed charges,70% of total billed charges,510.75,75,,,percent of total billed charges,75% of total billed charges,604.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,544.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1174.98,350,,,Fee Schedule,350% of CMS OPPS Rate,342.42,103,,,Fee Schedule,103% of CMS OPPS Rate,681,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,117.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,306.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,476.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,408.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,258.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,476.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,772.13,100,,,Fee Schedule,100% of CMS OPPS Rate,326.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,681,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,106.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,106.71,1188.41,
SPECIAL TX PROCEDURE,4250325,CDM,333,RC,77470,HCPCS,Outpatient,,,1890.9,1134.54,,1842.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,520.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1064.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1323.63,70,,,percent of total billed charges,70% of total billed charges,1418.18,75,,,percent of total billed charges,75% of total billed charges,936.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1512.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1821.5,350,,,Fee Schedule,350% of CMS OPPS Rate,530.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1446.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,325.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,850.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1323.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1134.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,1323.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.99,100,,,Fee Schedule,100% of CMS OPPS Rate,907.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1701.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,296.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,296.3,1842.32,
"New patient office or other outpatient visit, typically 30 min",4250403,CDM,510,RC,99203,HCPCS,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,228,
"New patient office of other outpatient visit, typically 45 min",4250404,CDM,510,RC,99204,HCPCS,Outpatient,,,389,233.4,,70.02,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,70.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.75,75,,,percent of total billed charges,75% of total billed charges,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,389,
Outpatient visit of established patient not requiring a physician,4250410,CDM,510,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
Outpatient visit of established patient requiring a physician,4250411,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",4250412,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",4250413,CDM,510,RC,99214,HCPCS,Outpatient,,,177,106.2,,31.86,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,31.86,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.75,75,,,percent of total billed charges,75% of total billed charges,88.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,141.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,123.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.26,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,123.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,177,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,159.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.86,177,
Guidance for localization of target delivery of radiation treatment delivery,4250421,CDM,333,RC,77387,HCPCS,Outpatient,,,193,115.8,,34.74,18,,,percent of total billed charges,pays at 18% of total charges,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.1,70,,,percent of total billed charges,70% of total billed charges,144.75,75,,,percent of total billed charges,75% of total billed charges,96.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,154.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,115.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705,100,,,Case rate,Pays based on per visit ,135.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,193,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,173.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,705,
SPECIAL PHYSICS CNSLT,4250520,CDM,333,RC,77370,HCPCS,Outpatient,,,689.7,413.82,,429.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,121.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,255.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,482.79,70,,,percent of total billed charges,70% of total billed charges,517.28,75,,,percent of total billed charges,75% of total billed charges,218.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,551.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,424.39,350,,,Fee Schedule,350% of CMS OPPS Rate,123.67,103,,,Fee Schedule,103% of CMS OPPS Rate,527.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,310.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,482.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,413.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,482.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,278.88,100,,,Fee Schedule,100% of CMS OPPS Rate,331.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,620.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,108.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,121.25,100,,,Fee Schedule,100% of CMS OPPS Rate,108.08,705,
NURSING OTV  PRODUCTIVITY ONLY,4250600,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INJECTION SQ OR IM,4250772,CDM,510,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,97.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
BRACHYTHERAPY HDR 1 CHANNEL,4250785,CDM,333,RC,77770,HCPCS,Outpatient,,,2004,1202.4,,2322.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,656.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1456,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1402.8,70,,,percent of total billed charges,70% of total billed charges,1503,75,,,percent of total billed charges,75% of total billed charges,1181,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1603.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2296.4,350,,,Fee Schedule,350% of CMS OPPS Rate,669.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1533.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,345.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,901.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1402.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1202.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,1402.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.06,100,,,Fee Schedule,100% of CMS OPPS Rate,961.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1803.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,314.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,314.03,2322.64,
BRACHYTHERAPY HDR 2-12 CHANNELS,4250786,CDM,333,RC,77771,HCPCS,Outpatient,,,1709,1025.4,,2322.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,656.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1456,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1196.3,70,,,percent of total billed charges,70% of total billed charges,1281.75,75,,,percent of total billed charges,75% of total billed charges,1181,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1367.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2296.4,350,,,Fee Schedule,350% of CMS OPPS Rate,669.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1307.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,294.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,769.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1196.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1025.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,1196.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.06,100,,,Fee Schedule,100% of CMS OPPS Rate,820.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,267.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,656.11,100,,,Fee Schedule,100% of CMS OPPS Rate,267.8,2322.64,
SUPERVISION/HANDLING RAD,4250790,CDM,333,RC,77790,HCPCS,Outpatient,,,286.2,171.72,,51.52,18,,,percent of total billed charges,pays at 18% of total charges,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,51.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.34,70,,,percent of total billed charges,70% of total billed charges,214.65,75,,,percent of total billed charges,75% of total billed charges,143.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,228.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,171.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,218.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,200.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,171.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,705,100,,,Case rate,Pays based on per visit ,200.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,286.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,257.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.85,705,
PROSTATE VOLUME STUDY FOR,4250873,CDM,402,RC,76873,HCPCS,Outpatient,,,403.04,241.82,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.13,70,,,percent of total billed charges,70% of total billed charges,302.28,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,308.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,181.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,282.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,193.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,362.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,63.16,446,
US INTERSTITIAL RE APPLIC,4250965,CDM,402,RC,76965,HCPCS,Outpatient,,,387.2,232.32,,69.7,18,,,percent of total billed charges,pays at 18% of total charges,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.7,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.04,70,,,percent of total billed charges,70% of total billed charges,290.4,75,,,percent of total billed charges,75% of total billed charges,193.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,309.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,271.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,387.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,348.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.67,446,
RAD/ONC CONSULT,4251000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
"Flexible, fiberoptic diagnostic laryngoscopy",4251575,CDM,360,RC,31575,HCPCS,Outpatient,,,424,254.4,,575.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,162.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,162.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,320.27,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,296.8,70,,,percent of total billed charges,70% of total billed charges,318,75,,,percent of total billed charges,75% of total billed charges,292.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,339.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.75,350,,,Fee Schedule,350% of CMS OPPS Rate,165.74,103,,,Fee Schedule,103% of CMS OPPS Rate,324.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,190.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,296.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,373.74,100,,,Fee Schedule,100% of CMS OPPS Rate,203.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,657,
BRACHY TX STRANDED I125,4252638,CDM,278,RC,C2638,HCPCS,Outpatient,,,125.4,75.24,,135.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.81,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,87.78,70,,,percent of total billed charges,70% of total billed charges,94.05,75,,,percent of total billed charges,75% of total billed charges,68.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.52,350,,,Fee Schedule,350% of CMS OPPS Rate,38.9,103,,,Fee Schedule,103% of CMS OPPS Rate,125.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,47.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,87.74,100,,,Fee Schedule,100% of CMS OPPS Rate,60.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,125.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,19.65,135.05,
Radiation Oncology   Productivity Only,4252638EX,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BRACHY TX STRANDED I125,4252638EX,CDM,278,RC,C2638,HCPCS,Outpatient,,,125.4,75.24,,135.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,70.81,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,87.78,70,,,percent of total billed charges,70% of total billed charges,94.05,75,,,percent of total billed charges,75% of total billed charges,68.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,133.52,350,,,Fee Schedule,350% of CMS OPPS Rate,38.9,103,,,Fee Schedule,103% of CMS OPPS Rate,125.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,47.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,87.74,100,,,Fee Schedule,100% of CMS OPPS Rate,60.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,125.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,38.15,100,,,Fee Schedule,100% of CMS OPPS Rate,19.65,135.05,
BRACHY TX STRANDED P103,4252640,CDM,278,RC,C2640,HCPCS,Outpatient,,,219.6,131.76,,313.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,160.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,153.72,70,,,percent of total billed charges,70% of total billed charges,164.7,75,,,percent of total billed charges,75% of total billed charges,159.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,175.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.2,350,,,Fee Schedule,350% of CMS OPPS Rate,90.4,103,,,Fee Schedule,103% of CMS OPPS Rate,219.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,83.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,100,,,Fee Schedule,100% of CMS OPPS Rate,105.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,219.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,313.75,
Radiation Oncology   Productivity Only,4252640EX,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BRACHY TX STRANDED P103,4252640EX,CDM,278,RC,C2640,HCPCS,Outpatient,,,219.6,131.76,,313.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,160.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,153.72,70,,,percent of total billed charges,70% of total billed charges,164.7,75,,,percent of total billed charges,75% of total billed charges,159.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,175.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,310.2,350,,,Fee Schedule,350% of CMS OPPS Rate,90.4,103,,,Fee Schedule,103% of CMS OPPS Rate,219.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,98.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,83.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,203.84,100,,,Fee Schedule,100% of CMS OPPS Rate,105.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,219.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,88.63,100,,,Fee Schedule,100% of CMS OPPS Rate,34.41,313.75,
IMPLANTABLE TISSUE MARKER,4254648,CDM,278,RC,A4648,HCPCS,Outpatient,,,322.3,193.38,,58.01,18,,,percent of total billed charges,pays at 18% of total charges,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.61,70,,,percent of total billed charges,70% of total billed charges,241.73,75,,,percent of total billed charges,75% of total billed charges,161.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,257.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,193.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,322.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.53,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,225.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,225.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,322.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,322.3,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.5,322.3,
INSERT UTERI TAN & OVOIDS,4255715,CDM,360,RC,57155,HCPCS,Outpatient,,,1375.2,825.12,,14916.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4213.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1375.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4633.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,962.64,70,,,percent of total billed charges,70% of total billed charges,1031.4,75,,,percent of total billed charges,75% of total billed charges,7584.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1100.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14748.22,350,,,Fee Schedule,350% of CMS OPPS Rate,1375.2,103,,,Fee Schedule,103% of CMS OPPS Rate,1052.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,618.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,962.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,825.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,962.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,9691.68,100,,,Fee Schedule,100% of CMS OPPS Rate,660.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1375.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1237.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4213.76,100,,,Fee Schedule,100% of CMS OPPS Rate,618.84,14916.76,
INSERT VAG APPLICATOR CYLINDER,4255716,CDM,342,RC,57156,HCPCS,Outpatient,,,733,439.8,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,733,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,547.14,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,513.1,70,,,percent of total billed charges,70% of total billed charges,549.75,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,586.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,270.72,103,,,Fee Schedule,103% of CMS OPPS Rate,560.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,329.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,513.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,513.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,351.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,659.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,733,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,1762,
TPRNLPLANT BIODEGRADABLE MATERIAL,4255874,CDM,333,RC,55874,HCPCS,Outpatient,,,11454,6872.4,,15132.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11454,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4274.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4274.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7556.22,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8017.8,70,,,percent of total billed charges,70% of total billed charges,8590.5,75,,,percent of total billed charges,75% of total billed charges,7694.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9163.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14961.63,350,,,Fee Schedule,350% of CMS OPPS Rate,4360.24,103,,,Fee Schedule,103% of CMS OPPS Rate,8762.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,5154.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8017.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6872.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,8017.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,9831.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5497.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,10308.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11454,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4274.75,100,,,Fee Schedule,100% of CMS OPPS Rate,705,15132.61,
"PLACE RT DEVICE/ MRK, PROS",4255876,CDM,490,RC,55876,HCPCS,Outpatient,,,3371,2022.6,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,528.24,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping Rate,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2359.7,70,,,percent of total billed charges,70% of total billed charges,2528.25,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,2578.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,580.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1516.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2359.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2022.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2359.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3033.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,528.24,4314.56,
US GUIDED NEEDLE PLACEMNT,4256942,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
IMRT/CONFORMAL RTH PLAN,4257301,CDM,333,RC,77301,HCPCS,Outpatient,,,3371,2022.6,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2359.7,70,,,percent of total billed charges,70% of total billed charges,2528.25,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2696.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,2578.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,580.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1516.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2359.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2022.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,2359.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3033.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,528.24,4314.56,
MCL DEVICE-BLK FOR IMRT,4257338,CDM,333,RC,77338,HCPCS,Outpatient,,,2957.45,1774.47,,1154.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,658.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2070.22,70,,,percent of total billed charges,70% of total billed charges,2218.09,75,,,percent of total billed charges,75% of total billed charges,586.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2365.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1141.39,350,,,Fee Schedule,350% of CMS OPPS Rate,332.63,103,,,Fee Schedule,103% of CMS OPPS Rate,2262.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,509.57,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2070.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1774.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,2070.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,750.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2661.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,463.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,100,,,Fee Schedule,100% of CMS OPPS Rate,326.11,2661.71,
Radiation therapy delivery,4257385,CDM,333,RC,77385,HCPCS,Outpatient,,,1837.45,1102.47,,1842.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,520.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1064.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1286.22,70,,,percent of total billed charges,70% of total billed charges,1378.09,75,,,percent of total billed charges,75% of total billed charges,936.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1469.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1821.5,350,,,Fee Schedule,350% of CMS OPPS Rate,530.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1405.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,316.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,826.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1286.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1102.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,1286.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.99,100,,,Fee Schedule,100% of CMS OPPS Rate,881.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1653.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,287.93,1842.32,
Radiation therapy delivery,4257386,CDM,333,RC,77386,HCPCS,Outpatient,,,2097.45,1258.47,,1842.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,520.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1064.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1468.22,70,,,percent of total billed charges,70% of total billed charges,1573.09,75,,,percent of total billed charges,75% of total billed charges,936.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1677.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1821.5,350,,,Fee Schedule,350% of CMS OPPS Rate,530.83,103,,,Fee Schedule,103% of CMS OPPS Rate,1604.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,943.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1468.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1258.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,1468.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1887.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,520.42,100,,,Fee Schedule,100% of CMS OPPS Rate,328.67,1887.71,
RAD TX DELIVERY SIMPL,4257402,CDM,333,RC,77402,HCPCS,Outpatient,,,332,199.2,,393.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,232.4,70,,,percent of total billed charges,70% of total billed charges,249,75,,,percent of total billed charges,75% of total billed charges,200.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,389.42,350,,,Fee Schedule,350% of CMS OPPS Rate,113.48,103,,,Fee Schedule,103% of CMS OPPS Rate,253.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,57.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,149.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,232.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,232.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,255.9,100,,,Fee Schedule,100% of CMS OPPS Rate,159.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,298.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,111.26,100,,,Fee Schedule,100% of CMS OPPS Rate,52.02,705,
RAD TX DELIVERY INT,4257407,CDM,333,RC,77407,HCPCS,Outpatient,,,268,160.8,,846.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,187.6,70,,,percent of total billed charges,70% of total billed charges,201,75,,,percent of total billed charges,75% of total billed charges,430.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.59,350,,,Fee Schedule,350% of CMS OPPS Rate,243.8,103,,,Fee Schedule,103% of CMS OPPS Rate,205.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,120.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,187.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,187.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,549.76,100,,,Fee Schedule,100% of CMS OPPS Rate,128.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,241.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,42,846.16,
Radiation treatment delivery,4257412,CDM,333,RC,77412,HCPCS,Outpatient,,,638.45,383.07,,846.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,448.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,446.92,70,,,percent of total billed charges,70% of total billed charges,478.84,75,,,percent of total billed charges,75% of total billed charges,430.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,510.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.59,350,,,Fee Schedule,350% of CMS OPPS Rate,243.8,103,,,Fee Schedule,103% of CMS OPPS Rate,488.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,287.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,446.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,383.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,446.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,549.76,100,,,Fee Schedule,100% of CMS OPPS Rate,306.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,574.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,100.05,846.16,
BRACHYTHERAPY HDR SKIN 1 CHANNEL,4257767,CDM,333,RC,77767,HCPCS,Outpatient,,,426,255.6,,846.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,448.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,298.2,70,,,percent of total billed charges,70% of total billed charges,319.5,75,,,percent of total billed charges,75% of total billed charges,430.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,340.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.59,350,,,Fee Schedule,350% of CMS OPPS Rate,243.8,103,,,Fee Schedule,103% of CMS OPPS Rate,325.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,73.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,191.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,298.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,255.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,298.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,549.76,100,,,Fee Schedule,100% of CMS OPPS Rate,204.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,383.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,66.75,846.16,
BRACHYTHERAPY HDR SKIN 2 OR MORE CHANNEL,4257768,CDM,333,RC,77768,HCPCS,Outpatient,,,511,306.6,,846.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,239.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,448.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,357.7,70,,,percent of total billed charges,70% of total billed charges,383.25,75,,,percent of total billed charges,75% of total billed charges,430.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,408.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,836.59,350,,,Fee Schedule,350% of CMS OPPS Rate,243.8,103,,,Fee Schedule,103% of CMS OPPS Rate,390.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,88.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,229.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,357.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,306.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,705,100,,,Case rate,Pays based on per visit ,357.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,549.76,100,,,Fee Schedule,100% of CMS OPPS Rate,245.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,459.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,239.03,100,,,Fee Schedule,100% of CMS OPPS Rate,80.07,846.16,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",4258952,CDM,510,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,188.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
ORAL RADIOPHARM RX,4259005,CDM,342,RC,79005,HCPCS,Outpatient,,,648.56,389.14,,803.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,227.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,486.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,453.99,70,,,percent of total billed charges,70% of total billed charges,486.42,75,,,percent of total billed charges,75% of total billed charges,408.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,518.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,794.59,350,,,Fee Schedule,350% of CMS OPPS Rate,231.56,103,,,Fee Schedule,103% of CMS OPPS Rate,496.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,111.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,291.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,453.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,389.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,453.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,522.16,100,,,Fee Schedule,100% of CMS OPPS Rate,311.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,583.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,101.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,101.63,1762,
RADIOPHARMACEUTICAL IV,4259101,CDM,342,RC,79101,HCPCS,Outpatient,,,643,385.8,,803.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,227.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,486.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,450.1,70,,,percent of total billed charges,70% of total billed charges,482.25,75,,,percent of total billed charges,75% of total billed charges,408.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,514.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,794.59,350,,,Fee Schedule,350% of CMS OPPS Rate,231.56,103,,,Fee Schedule,103% of CMS OPPS Rate,491.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,110.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,289.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,450.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,385.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,1762,100,,,Case rate,Pays based on per visit ,450.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,522.16,100,,,Fee Schedule,100% of CMS OPPS Rate,308.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,578.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,100.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,227.03,100,,,Fee Schedule,100% of CMS OPPS Rate,100.76,1762,
PLACE RT DEVICE/ MRK ABD,4259411,CDM,490,RC,49411,HCPCS,Outpatient,,,1534.4,920.64,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,359.35,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping Rate,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1074.08,70,,,percent of total billed charges,70% of total billed charges,1150.8,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1227.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1173.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1074.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,920.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1074.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,736.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,359.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,359.35,4314.56,
IODINE I 131 CAPSULE(S) PER MILLICURIE,4259516,CDM,636,RC,A9517,HCPCS,Outpatient,,,40.7,24.42,,84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.35,50,,,percent of total billed charges,pays at 50% of total billed charges,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,42.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.05,350,,,Fee Schedule,350% of CMS OPPS Rate,24.2,103,,,Fee Schedule,103% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,15.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,54.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,84,
Radiation Oncology   Productivity Only,4259516EX,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
IODINE I 131 CAPSULE(S) PER MILLICURIE,4259516EX,CDM,636,RC,A9517,HCPCS,Outpatient,,,40.7,24.42,,84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.35,50,,,percent of total billed charges,pays at 50% of total billed charges,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,42.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.05,350,,,Fee Schedule,350% of CMS OPPS Rate,24.2,103,,,Fee Schedule,103% of CMS OPPS Rate,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,15.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,54.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,23.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.38,84,
SR89 STRONTIUM per mCi,4259600,CDM,344,RC,A9600,HCPCS,Outpatient,,,2412,1447.2,,14071.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3975,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2412,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1206,50,,,percent of total billed charges,pays at 50% of total billed charges,1688.4,70,,,percent of total billed charges,70% of total billed charges,1809,75,,,percent of total billed charges,75% of total billed charges,7155,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1929.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13912.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2412,103,,,Fee Schedule,103% of CMS OPPS Rate,1845.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,1085.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1688.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1447.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,916.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1688.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,9142.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1157.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2412,100,,,Fee Schedule,100% of CMS OPPS Rate,2170.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,3975,100,,,Fee Schedule,100% of CMS OPPS Rate,916.56,14071.5,
SM 153 LEXIDRONAM,4259604,CDM,344,RC,A9604,HCPCS,Outpatient,,,9154.4,5492.64,,61099.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17259.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9154.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4577.2,50,,,percent of total billed charges,pays at 50% of total billed charges,6408.08,70,,,percent of total billed charges,70% of total billed charges,6865.8,75,,,percent of total billed charges,75% of total billed charges,31067.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,7323.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60409.47,350,,,Fee Schedule,350% of CMS OPPS Rate,9154.4,103,,,Fee Schedule,103% of CMS OPPS Rate,7003.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,4119.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6408.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5492.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3478.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6408.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,39697.65,100,,,Fee Schedule,100% of CMS OPPS Rate,4394.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,8238.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17259.84,100,,,Fee Schedule,100% of CMS OPPS Rate,3478.67,61099.86,
RADIUM 223 (XOFIGO) per mci,4259606,CDM,344,RC,A9606,HCPCS,Outpatient,,,170.75,102.45,,559,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,157.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.38,50,,,percent of total billed charges,pays at 50% of total billed charges,119.53,70,,,percent of total billed charges,70% of total billed charges,128.06,75,,,percent of total billed charges,75% of total billed charges,284.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.66,350,,,Fee Schedule,350% of CMS OPPS Rate,161.06,103,,,Fee Schedule,103% of CMS OPPS Rate,130.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,76.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,64.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,363.19,100,,,Fee Schedule,100% of CMS OPPS Rate,81.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,153.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,64.89,559,
Radiation Oncology   Productivity Only,4259606EX,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
RADIUM 223 (XOFIGO) per mci,4259606EX,CDM,344,RC,A9606,HCPCS,Outpatient,,,170.75,102.45,,559,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,157.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,85.38,50,,,percent of total billed charges,pays at 50% of total billed charges,119.53,70,,,percent of total billed charges,70% of total billed charges,128.06,75,,,percent of total billed charges,75% of total billed charges,284.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,552.66,350,,,Fee Schedule,350% of CMS OPPS Rate,161.06,103,,,Fee Schedule,103% of CMS OPPS Rate,130.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,76.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,64.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,363.19,100,,,Fee Schedule,100% of CMS OPPS Rate,81.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,153.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,64.89,559,
BRACHYTHERAPY NEEDLE,4259905,CDM,272,RC,C1715,HCPCS,Outpatient,,,45.1,27.06,,8.12,18,,,percent of total billed charges,pays at 18% of total charges,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,22.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.07,45.1,
Radiation Oncology   Productivity Only,4259905EX,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BRACHYTHERAPY NEEDLE,4259905EX,CDM,272,RC,C1715,HCPCS,Outpatient,,,45.1,27.06,,8.12,18,,,percent of total billed charges,pays at 18% of total charges,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.57,70,,,percent of total billed charges,70% of total billed charges,33.83,75,,,percent of total billed charges,75% of total billed charges,22.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.07,45.1,
Radiation Oncology   Productivity Only,4259967EX,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Radiation Oncology   Productivity Only,4259999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
"MYELOGRAM, CERVICAL",427-2240,CDM,320,RC,62302,HCPCS,Outpatient,,,876,525.6,,2383.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,613.2,70,,,percent of total billed charges,70% of total billed charges,657,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,700.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.95,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,670.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,150.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,394.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,613.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,613.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,420.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,788.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,137.27,2383.89,
"MYELOGRAM, CERVICAL",427-2240T,CDM,320,RC,72240,HCPCS,Outpatient,,,876,525.6,,2383.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,613.2,70,,,percent of total billed charges,70% of total billed charges,657,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,700.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.95,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,670.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,150.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,394.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,613.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,613.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,420.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,788.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,137.27,2383.89,
"MYELOGRAM,THORACIC",4272255,CDM,320,RC,62303,HCPCS,Outpatient,,,762,457.2,,2383.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,533.4,70,,,percent of total billed charges,70% of total billed charges,571.5,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.95,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,582.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,342.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,533.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,533.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,365.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,685.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,119.41,2383.89,
TRAY MYELGRAM,4272255E,CDM,272,RC,,,Outpatient,,,320.5,192.3,,57.69,18,,,percent of total billed charges,pays at 18% of total charges,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.69,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.25,50,,,percent of total billed charges,pays at 50% of total billed charges,224.35,70,,,percent of total billed charges,70% of total billed charges,240.38,75,,,percent of total billed charges,75% of total billed charges,160.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,256.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,192.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,245.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,224.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,320.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,288.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,320.5,
"MYELOGRAM,THORACIC",4272255E,CDM,320,RC,62303,HCPCS,Outpatient,,,762,457.2,,2383.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,533.4,70,,,percent of total billed charges,70% of total billed charges,571.5,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.95,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,582.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,131.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,342.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,533.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,533.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,365.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,685.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,119.41,2383.89,
"MYELOGRAM, LUMBOSACRAL",427-2265,CDM,320,RC,62304,HCPCS,Outpatient,,,876,525.6,,2383.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,613.2,70,,,percent of total billed charges,70% of total billed charges,657,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,700.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.95,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,670.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,150.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,394.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,613.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,613.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,420.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,788.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,137.27,2383.89,
MYELOGRAM 2 OR > REGIONS,427-2270,CDM,320,RC,62305,HCPCS,Outpatient,,,1190.4,714.24,,2383.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,673.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1390.29,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,833.28,70,,,percent of total billed charges,70% of total billed charges,892.8,75,,,percent of total billed charges,75% of total billed charges,1212.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,952.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2356.95,350,,,Fee Schedule,350% of CMS OPPS Rate,686.88,103,,,Fee Schedule,103% of CMS OPPS Rate,910.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,535.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,833.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,714.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,833.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.85,100,,,Fee Schedule,100% of CMS OPPS Rate,571.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,186.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,100,,,Fee Schedule,100% of CMS OPPS Rate,186.54,2383.89,
SHOULDER ARTHOGRAM S&I LEFT,4273040,CDM,320,RC,73040,HCPCS,Outpatient,,,501.6,300.96,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,351.12,70,,,percent of total billed charges,70% of total billed charges,376.2,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,401.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,383.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,240.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,451.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,78.6,1185.68,
SHOULDER ARTHOGRAM S&I RIGHT,4273040RT,CDM,320,RC,73040,HCPCS,Outpatient,,,501.6,300.96,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,351.12,70,,,percent of total billed charges,70% of total billed charges,376.2,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,401.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,383.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,86.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,240.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,451.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,78.6,1185.68,
ELBOW ARTHOGRAM LT,4273085,CDM,320,RC,73085,HCPCS,Outpatient,,,365.86,219.52,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.1,70,,,percent of total billed charges,70% of total billed charges,274.4,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,164.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,175.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,329.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,57.33,1185.68,
ELBOW ARTHOGRAM RT,4273085RT,CDM,320,RC,73085,HCPCS,Outpatient,,,365.86,219.52,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.1,70,,,percent of total billed charges,70% of total billed charges,274.4,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,164.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,175.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,329.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,57.33,1185.68,
WRIST ARTHROGRAPHY LT,4273115,CDM,322,RC,73115,HCPCS,Outpatient,,,376.15,225.69,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,263.31,70,,,percent of total billed charges,70% of total billed charges,282.11,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,300.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,287.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,338.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,1185.68,
WRIST ARTHROGRAPHY RT,4273115RT,CDM,322,RC,73115,HCPCS,Outpatient,,,376.15,225.69,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,263.31,70,,,percent of total billed charges,70% of total billed charges,282.11,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,300.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,287.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,338.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,1185.68,
FLUORO GUIDED NDL PLCMNT RIGHT,4273115RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4273115RTE,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4273350,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
SHOULDER ARTHRO INJ LT,4273350,CDM,320,RC,23350,HCPCS,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,515.31,
FLUORO GUIDED NDL PLCMNT RIGHT,4273350RT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
SHOULDER ARTHRO INJ RIGHT,4273350RT,CDM,320,RC,23350,HCPCS,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,515.31,
HIP ARTHOGRAM LT,4273525,CDM,320,RC,73525,HCPCS,Outpatient,,,370.26,222.16,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,259.18,70,,,percent of total billed charges,70% of total billed charges,277.7,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,296.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,283.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,166.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,333.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,58.02,1185.68,
Draining or injecting medication into a major joint/bursa without ultrasound,4273525E,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4273525E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
HIP ARTHOGRAM RT,4273525RT,CDM,320,RC,73525,HCPCS,Outpatient,,,370.26,222.16,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,259.18,70,,,percent of total billed charges,70% of total billed charges,277.7,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,296.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,283.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,63.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,166.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,333.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,58.02,1185.68,
FLUORO GUIDED NDL PLCMNT RIGHT,4273525RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4273525RTE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
KNEE ARTHOGRAM LT,4273580,CDM,320,RC,73580,HCPCS,Outpatient,,,526,315.6,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,368.2,70,,,percent of total billed charges,70% of total billed charges,394.5,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,402.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,236.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,473.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,82.42,1185.68,
Draining or injecting medication into a major joint/bursa without ultrasound,4273580E,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4273580E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
KNEE ARTHOGRAM RT,4273580RT,CDM,320,RC,73580,HCPCS,Outpatient,,,526,315.6,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,368.2,70,,,percent of total billed charges,70% of total billed charges,394.5,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,402.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,90.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,236.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,473.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,82.42,1185.68,
FLUORO GUIDED NDL PLCMNT RIGHT,4273580RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4273580RTE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
ANKLE ARTHOGRAM LT,4273615,CDM,320,RC,73615,HCPCS,Outpatient,,,350.61,210.37,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.43,70,,,percent of total billed charges,70% of total billed charges,262.96,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,280.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,268.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,157.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,315.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,54.94,1185.68,
ANKLE ARTHOGRAM RT,4273615RT,CDM,320,RC,73615,HCPCS,Outpatient,,,350.61,210.37,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.43,70,,,percent of total billed charges,70% of total billed charges,262.96,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,280.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,268.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,157.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,315.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,54.94,1185.68,
FLUORO GUIDED NDL PLCMNT RIGHT,4273615RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4273615RTE,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
NG TUBE PLCMT,4273752,CDM,360,RC,43752,HCPCS,Outpatient,,,292.4,175.44,,1215.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,343.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,292.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,672.86,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,204.68,70,,,percent of total billed charges,70% of total billed charges,219.3,75,,,percent of total billed charges,75% of total billed charges,617.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,233.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1201.37,350,,,Fee Schedule,350% of CMS OPPS Rate,292.4,103,,,Fee Schedule,103% of CMS OPPS Rate,223.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,131.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,204.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,204.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,789.47,100,,,Fee Schedule,100% of CMS OPPS Rate,140.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,292.4,100,,,Fee Schedule,100% of CMS OPPS Rate,263.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,131.58,1215.1,
ESOPHOGRAM,4274220,CDM,320,RC,74220,HCPCS,Outpatient,,,493,295.8,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,345.1,70,,,percent of total billed charges,70% of total billed charges,369.75,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,443.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.25,580.37,
SWALLOWING FCN W CINEVIDE,4274230,CDM,320,RC,74230,HCPCS,Outpatient,,,493,295.8,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,345.1,70,,,percent of total billed charges,70% of total billed charges,369.75,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,443.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.25,580.37,
UPPER GI,4274240,CDM,320,RC,74240,HCPCS,Outpatient,,,493,295.8,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,345.1,70,,,percent of total billed charges,70% of total billed charges,369.75,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,443.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.25,580.37,
UGI W SM BOWEL,4274245,CDM,320,RC,74248,HCPCS,Outpatient,,,292.4,175.44,,52.63,18,,,percent of total billed charges,pays at 18% of total charges,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.2,50,,,percent of total billed charges,pays at 50% of total billed charges,204.68,70,,,percent of total billed charges,70% of total billed charges,219.3,75,,,percent of total billed charges,75% of total billed charges,146.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,204.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,204.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,292.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,263.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.82,364,
UPPER GI WITH AIR,4274246,CDM,320,RC,74246,HCPCS,Outpatient,,,493,295.8,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,345.1,70,,,percent of total billed charges,70% of total billed charges,369.75,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,443.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.25,580.37,
UPPER GI WITH AIR W/ SBFT,4274249,CDM,320,RC,74248,HCPCS,Outpatient,,,292.4,175.44,,52.63,18,,,percent of total billed charges,pays at 18% of total charges,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.2,50,,,percent of total billed charges,pays at 50% of total billed charges,204.68,70,,,percent of total billed charges,70% of total billed charges,219.3,75,,,percent of total billed charges,75% of total billed charges,146.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,233.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,175.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,204.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,204.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,292.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,263.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.82,364,
SMALL BOWEL-EC,4274250,CDM,320,RC,74250,HCPCS,Outpatient,,,,,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,580.37,
SMALL BOWEL,4274250,CDM,320,RC,74250,HCPCS,Outpatient,,,493,295.8,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,345.1,70,,,percent of total billed charges,70% of total billed charges,369.75,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,443.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.25,580.37,
BE COLON W/WO KUB,4274270,CDM,320,RC,74270,HCPCS,Outpatient,,,263.56,158.14,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.49,70,,,percent of total billed charges,70% of total billed charges,197.67,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,201.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,118.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,184.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,126.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,237.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.3,580.37,
BARIUM ENEMA W/AIR,4274280,CDM,320,RC,74280,HCPCS,Outpatient,,,493,295.8,,580.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,163.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,345.1,70,,,percent of total billed charges,70% of total billed charges,369.75,75,,,percent of total billed charges,75% of total billed charges,295.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,394.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,573.81,350,,,Fee Schedule,350% of CMS OPPS Rate,167.22,103,,,Fee Schedule,103% of CMS OPPS Rate,377.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,295.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,345.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,443.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,163.94,100,,,Fee Schedule,100% of CMS OPPS Rate,77.25,580.37,
POSTOP CHOLANGIOGRAM,4274305,CDM,320,RC,47531,HCPCS,Outpatient,,,8416,5049.6,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5891.2,70,,,percent of total billed charges,70% of total billed charges,6312,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,6732.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,6438.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1450.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3787.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5891.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5049.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,5891.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,4039.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7574.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1318.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,364,11398.68,
ENDO CATH - BIL/PANCR D,4274330,CDM,320,RC,74330,HCPCS,Outpatient,,,468,280.8,,84.24,18,,,percent of total billed charges,pays at 18% of total charges,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.6,70,,,percent of total billed charges,70% of total billed charges,351,75,,,percent of total billed charges,75% of total billed charges,234,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,374.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,358.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,327.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,280.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,327.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,468,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,421.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.34,468,
GI TUBE INTRODUCTION,4274340,CDM,320,RC,74340,HCPCS,Outpatient,,,384.8,230.88,,69.26,18,,,percent of total billed charges,pays at 18% of total charges,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.36,70,,,percent of total billed charges,70% of total billed charges,288.6,75,,,percent of total billed charges,75% of total billed charges,192.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,269.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,269.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,384.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,346.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.3,384.8,
ANTEGRADE UROGRAPHY DIAGNOSTIC,4274425,CDM,320,RC,74425,HCPCS,Outpatient,,,266.56,159.94,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,266.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,186.59,70,,,percent of total billed charges,70% of total billed charges,199.92,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,213.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,266.56,103,,,Fee Schedule,103% of CMS OPPS Rate,203.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,186.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,127.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,266.56,100,,,Fee Schedule,100% of CMS OPPS Rate,239.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,1185.68,
INJECT FOR PYELOGRAPHY,4274425E,CDM,320,RC,50430,HCPCS,Outpatient,,,144.57,86.74,,2012.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,144.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1153.2,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,101.2,70,,,percent of total billed charges,70% of total billed charges,108.43,75,,,percent of total billed charges,75% of total billed charges,1023.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1989.73,350,,,Fee Schedule,350% of CMS OPPS Rate,144.57,103,,,Fee Schedule,103% of CMS OPPS Rate,110.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,65.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,101.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,101.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1307.54,100,,,Fee Schedule,100% of CMS OPPS Rate,69.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144.57,100,,,Fee Schedule,100% of CMS OPPS Rate,130.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,22.65,2012.47,
ANTEGRADE UROGRAPHY DIAGNOSTIC,4274425E,CDM,320,RC,74425,HCPCS,Outpatient,,,266.56,159.94,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,266.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,186.59,70,,,percent of total billed charges,70% of total billed charges,199.92,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,213.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,266.56,103,,,Fee Schedule,103% of CMS OPPS Rate,203.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,186.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,127.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,266.56,100,,,Fee Schedule,100% of CMS OPPS Rate,239.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,41.77,1185.68,
"CYSTOGRAM, MIN 3 VIEWS",4274430,CDM,320,RC,74430,HCPCS,Outpatient,,,1034,620.4,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,723.8,70,,,percent of total billed charges,70% of total billed charges,775.5,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,827.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,791.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,178.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,465.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,723.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,620.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,723.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,496.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,930.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,162.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,162.03,1185.68,
"URETHOGRAM, RETROGRADE",4274450,CDM,320,RC,74450,HCPCS,Outpatient,,,258.8,155.28,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,181.16,70,,,percent of total billed charges,70% of total billed charges,194.1,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,207.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,197.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,116.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,181.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,181.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,124.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,232.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,40.55,751.51,
URETHOCYSTOGRAM-VOIDING,4274455,CDM,320,RC,74455,HCPCS,Outpatient,,,631,378.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,482.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,567.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,98.88,751.51,
HYSTEROSALPINGOGRAM,427-4740,CDM,320,RC,74740,HCPCS,Outpatient,,,631,378.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,482.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,567.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,98.88,751.51,
HSG CATHETER,4274740E,CDM,272,RC,,,Outpatient,,,149.05,89.43,,26.83,18,,,percent of total billed charges,pays at 18% of total charges,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.53,50,,,percent of total billed charges,pays at 50% of total billed charges,104.34,70,,,percent of total billed charges,70% of total billed charges,111.79,75,,,percent of total billed charges,75% of total billed charges,74.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,119.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,56.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,149.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,134.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.36,149.05,
TRAY HYSTERO,4274740E,CDM,272,RC,,,Outpatient,,,119.9,71.94,,21.58,18,,,percent of total billed charges,pays at 18% of total charges,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,59.95,50,,,percent of total billed charges,pays at 50% of total billed charges,83.93,70,,,percent of total billed charges,70% of total billed charges,89.93,75,,,percent of total billed charges,75% of total billed charges,59.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,95.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,71.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,83.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,119.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,107.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.79,119.9,
HYSTEROG/SIS CONTR/SALINE,4274740E,CDM,360,RC,58340,HCPCS,Outpatient,,,277.2,166.32,,49.9,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,49.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,194.04,70,,,percent of total billed charges,70% of total billed charges,207.9,75,,,percent of total billed charges,75% of total billed charges,138.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,221.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,212.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,194.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,249.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.9,657,
HYSTEROSALPINGOGRAM,4274740E,CDM,320,RC,74740,HCPCS,Outpatient,,,631,378.6,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441.7,70,,,percent of total billed charges,70% of total billed charges,473.25,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,482.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.72,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,283.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,441.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,302.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,567.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,98.88,751.51,
"VENOGRAM,EXTREMITY LEFT",4275820,CDM,320,RC,75820,HCPCS,Outpatient,,,1280,768,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,896,70,,,percent of total billed charges,70% of total billed charges,960,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1024,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1280,103,,,Fee Schedule,103% of CMS OPPS Rate,979.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,576,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,614.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1280,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,200.58,4788.21,
"VENOGRAM,EXTREMITY RIGHT",4275820RT,CDM,320,RC,75820,HCPCS,Outpatient,,,1280,768,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,896,70,,,percent of total billed charges,70% of total billed charges,960,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1024,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1280,103,,,Fee Schedule,103% of CMS OPPS Rate,979.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,576,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,614.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1280,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,200.58,4788.21,
"VENOGRAM,EXTREMITY BILAT",4275822,CDM,320,RC,75820,HCPCS,Outpatient,,,1280,768,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,896,70,,,percent of total billed charges,70% of total billed charges,960,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1024,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1280,103,,,Fee Schedule,103% of CMS OPPS Rate,979.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,576,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,614.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1280,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,200.58,4788.21,
EXTREM VENOGRAM INJ RIGHT,4275822E,CDM,320,RC,36005,HCPCS,Outpatient,,,2000,1200,,360,18,,,percent of total billed charges,pays at 18% of total charges,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.4,2000,
EXTREM VENOGRAM INJ LT,4275822E,CDM,320,RC,36005,HCPCS,Outpatient,,,2000,1200,,360,18,,,percent of total billed charges,pays at 18% of total charges,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,360,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,1000,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,344.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2000,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,313.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.4,2000,
"VENOGRAM,EXTREMITY BILAT",4275822E,CDM,320,RC,75820,HCPCS,Outpatient,,,1280,768,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,896,70,,,percent of total billed charges,70% of total billed charges,960,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1024,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1280,103,,,Fee Schedule,103% of CMS OPPS Rate,979.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,220.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,576,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,614.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1280,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,200.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,200.58,4788.21,
FLUORO GUIDED CENTRAL VAD,4275998,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",4276000,CDM,320,RC,76000,HCPCS,Outpatient,,,833.76,500.26,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,583.63,70,,,percent of total billed charges,70% of total billed charges,625.32,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,667.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,637.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,375.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,400.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,750.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,130.65,751.51,
FLUORO GUIDED NDL PLCMNT LEFT,4276003,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
FLUORO GUIDED NDL PLCMNT LEFT,4276003AASPLT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003AASPLT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003AASPRT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003AASPRT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003AINJLT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003AINJLT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003AINJRT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003AINJRT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003ALE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003ALE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003ARE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003ARE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003E,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
FLUORO GUIDED NDL PLCMNT LEFT,4276003EASPLT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003EASPLT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003EASPRT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003EASPRT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003HALE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003HALE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003HARE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003HARE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003HILE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003HILE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003HIRE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003HIRE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003ILE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003ILE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003KALE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003KALE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003KARE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003KARE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
FLUORO GUIDED NDL PLCMNT LEFT,4276003LT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003RT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,4276003RTE,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
FLUORO GUIDED NDL PLCMNT LEFT,4276003WASPLT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003WASPLT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT RIGHT,4276003WASPRT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003WASPRT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003WINJLT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003WINJLT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FLUORO GUIDED NDL PLCMNT LEFT,4276003WINJRT,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a large joint/bursa without ultrasound,4276003WINJRT,CDM,360,RC,20605,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
FISTULA/SINUS TRACT STY,4276080,CDM,320,RC,76080,HCPCS,Outpatient,,,355.76,213.46,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,355.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.03,70,,,percent of total billed charges,70% of total billed charges,266.82,75,,,percent of total billed charges,75% of total billed charges,823.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,284.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.88,350,,,Fee Schedule,350% of CMS OPPS Rate,355.76,103,,,Fee Schedule,103% of CMS OPPS Rate,272.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,160.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,249.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,170.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,355.76,100,,,Fee Schedule,100% of CMS OPPS Rate,320.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,55.75,1619.18,
FISTULA/SINUS TRACT,4276080E,CDM,320,RC,20501,HCPCS,Outpatient,,,165.44,99.26,,29.78,18,,,percent of total billed charges,pays at 18% of total charges,165.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,29.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,115.81,70,,,percent of total billed charges,70% of total billed charges,124.08,75,,,percent of total billed charges,75% of total billed charges,82.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,115.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,165.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,148.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.78,473.66,
FISTULA/SINUS TRACT STY,4276080E,CDM,320,RC,76080,HCPCS,Outpatient,,,355.76,213.46,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,355.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.03,70,,,percent of total billed charges,70% of total billed charges,266.82,75,,,percent of total billed charges,75% of total billed charges,823.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,284.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.88,350,,,Fee Schedule,350% of CMS OPPS Rate,355.76,103,,,Fee Schedule,103% of CMS OPPS Rate,272.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,61.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,160.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,249.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,170.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,355.76,100,,,Fee Schedule,100% of CMS OPPS Rate,320.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,55.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,55.75,1619.18,
FLUORO FOR SPINE INJECT,4276227E,CDM,320,RC,77003,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
LUMBAR PUNCTURE,4276227E,CDM,360,RC,62328,HCPCS,Outpatient,,,1692,1015.2,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,846,50,,,percent of total billed charges,pays at 50% of total billed charges,1184.4,70,,,percent of total billed charges,70% of total billed charges,1269,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1353.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,1294.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,761.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1015.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1184.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,812.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1522.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,2073.62,
FLUORO FOR SPINE INJECT,4277003,CDM,320,RC,77003,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
ADDITIONAL FLUORO HOURS,4277801,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
FLUORO FOR SPINE INJECTIONS,427LESI,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
CHRGE TIME GS HALTH.1/4HR,4281464,CDM,370,RC,,,Outpatient,,,47,28.2,,8.46,18,,,percent of total billed charges,pays at 18% of total charges,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.5,50,,,percent of total billed charges,pays at 50% of total billed charges,32.9,70,,,percent of total billed charges,70% of total billed charges,35.25,75,,,percent of total billed charges,75% of total billed charges,23.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,37.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,47,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,42.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.36,47,
CHRGE TIME GS NITS.1/4HR,4281466,CDM,370,RC,,,Outpatient,,,40.7,24.42,,7.33,18,,,percent of total billed charges,pays at 18% of total charges,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.33,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.35,50,,,percent of total billed charges,pays at 50% of total billed charges,28.49,70,,,percent of total billed charges,70% of total billed charges,30.53,75,,,percent of total billed charges,75% of total billed charges,20.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.47,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,40.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.38,40.7,
CHRGE TIME GAS ETHR.1/4HR,4281467,CDM,370,RC,,,Outpatient,,,143,85.8,,25.74,18,,,percent of total billed charges,pays at 18% of total charges,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.5,50,,,percent of total billed charges,pays at 50% of total billed charges,100.1,70,,,percent of total billed charges,70% of total billed charges,107.25,75,,,percent of total billed charges,75% of total billed charges,71.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,114.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,109.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,54.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,100.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,143,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,128.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.41,143,
CHRGE TIME GAS FORN.1/4HR,4281468,CDM,370,RC,,,Outpatient,,,200,120,,36,18,,,percent of total billed charges,pays at 18% of total charges,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,100,50,,,percent of total billed charges,pays at 50% of total billed charges,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,200,
ANESTH MOD SED RN MONITORED 1MIN,4281469,CDM,370,RC,,,Outpatient,,,4.84,2.9,,0.87,18,,,percent of total billed charges,pays at 18% of total charges,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.42,50,,,percent of total billed charges,pays at 50% of total billed charges,3.39,70,,,percent of total billed charges,70% of total billed charges,3.63,75,,,percent of total billed charges,75% of total billed charges,2.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,4.84,
CHRGE TIME GAS SUPR.1/4HR,4281472,CDM,370,RC,,,Outpatient,,,203.5,122.1,,36.63,18,,,percent of total billed charges,pays at 18% of total charges,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.75,50,,,percent of total billed charges,pays at 50% of total billed charges,142.45,70,,,percent of total billed charges,70% of total billed charges,152.63,75,,,percent of total billed charges,75% of total billed charges,101.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.89,203.5,
ANESTHESIA GENERAL 1 MIN,4281473,CDM,370,RC,,,Outpatient,,,75,45,,13.5,18,,,percent of total billed charges,pays at 18% of total charges,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.5,50,,,percent of total billed charges,pays at 50% of total billed charges,52.5,70,,,percent of total billed charges,70% of total billed charges,56.25,75,,,percent of total billed charges,75% of total billed charges,37.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,52.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.75,75,
CHRGE TIME GAS ULTR.1/4HR,4281474,CDM,370,RC,,,Outpatient,,,203.5,122.1,,36.63,18,,,percent of total billed charges,pays at 18% of total charges,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,101.75,50,,,percent of total billed charges,pays at 50% of total billed charges,142.45,70,,,percent of total billed charges,70% of total billed charges,152.63,75,,,percent of total billed charges,75% of total billed charges,101.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.89,203.5,
ANESTHESIA LOCAL 1 MIN RN MONITORED,4281475,CDM,370,RC,,,Outpatient,,,4.84,2.9,,0.87,18,,,percent of total billed charges,pays at 18% of total charges,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.87,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.42,50,,,percent of total billed charges,pays at 50% of total billed charges,3.39,70,,,percent of total billed charges,70% of total billed charges,3.63,75,,,percent of total billed charges,75% of total billed charges,2.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,3.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.76,4.84,
ANESTHESIA MAC 1 MIN,4281476,CDM,370,RC,,,Outpatient,,,9,5.4,,1.62,18,,,percent of total billed charges,pays at 18% of total charges,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.5,50,,,percent of total billed charges,pays at 50% of total billed charges,6.3,70,,,percent of total billed charges,70% of total billed charges,6.75,75,,,percent of total billed charges,75% of total billed charges,4.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.41,9,
ANESTHESIA REGIONAL 1 MIN,4281477,CDM,370,RC,,,Outpatient,,,12,7.2,,2.16,18,,,percent of total billed charges,pays at 18% of total charges,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6,50,,,percent of total billed charges,pays at 50% of total billed charges,8.4,70,,,percent of total billed charges,70% of total billed charges,9,75,,,percent of total billed charges,75% of total billed charges,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12,
ANESTHESIA SPINAL 1 MIN,4281478,CDM,370,RC,,,Outpatient,,,12,7.2,,2.16,18,,,percent of total billed charges,pays at 18% of total charges,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6,50,,,percent of total billed charges,pays at 50% of total billed charges,8.4,70,,,percent of total billed charges,70% of total billed charges,9,75,,,percent of total billed charges,75% of total billed charges,6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.88,12,
ANESTHESIA GENERAL 1 MIN,4281479,CDM,370,RC,,,Outpatient,,,12.1,7.26,,2.18,18,,,percent of total billed charges,pays at 18% of total charges,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,6.05,50,,,percent of total billed charges,pays at 50% of total billed charges,8.47,70,,,percent of total billed charges,70% of total billed charges,9.08,75,,,percent of total billed charges,75% of total billed charges,6.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,9.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,8.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.81,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,12.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.9,12.1,
MANDIBLE 1-4 VWS,4290100,CDM,320,RC,70100,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
MANDIBLE COMPLETE,4290110,CDM,320,RC,70110,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
CHEST MIN OF 4-VWS,4291030,CDM,324,RC,71030,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
CHEST SPECIAL VIEWS,4291035,CDM,324,RC,71035,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
RIBS BILATERAL 3 VIEWS,4291110,CDM,320,RC,71110,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
HIP BILAT X-RAY,4293520,CDM,320,RC,73520,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
Radiologic examination of both knees,4297077,CDM,320,RC,73565,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
ABDOMEN (KUB),4299301,CDM,320,RC,74018,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
COMPLETE ABDOMEN,4299302,CDM,320,RC,74020,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
ORBITS COMPLETE MIN 4 VWS,4299308,CDM,320,RC,70200,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
STERNUM-MIN 2 VIEWS,4299312,CDM,320,RC,71120,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
FACIAL BONES,4299314,CDM,320,RC,70150,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
Radiologic examination of the toe(s),4299318,CDM,320,RC,73660,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the toe(s),4299318RT,CDM,320,RC,73660,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the heel,4299320,CDM,320,RC,73650,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the heel,4299320RT,CDM,320,RC,73650,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
NASAL BONES COMPLETE,4299324,CDM,320,RC,70160,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
SACROLILIAC JOINTS COM,4299326,CDM,320,RC,72202,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
SCAPULA COMPLETE,4299330,CDM,320,RC,73010,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
Single view,4299332,CDM,320,RC,71045,HCPCS,Outpatient,,,,,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
"2 views, front and back",4299334,CDM,320,RC,71046,HCPCS,Outpatient,,,,,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
CHEST LORDOTIC,4299338,CDM,320,RC,71021,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
LAT DECUBITUS CHEST,4299340,CDM,320,RC,71035,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
RIBS UNIL-2 VIEWS LEFT,4299342,CDM,320,RC,71100,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
RIBS UNIL-2 VIEWS RIGHT,4299342RT,CDM,320,RC,71100,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
SKULL COMPLETE MIN 4 VIEW,4299346,CDM,320,RC,70260,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
"SINUS, COMPLETE",4299348,CDM,320,RC,70220,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
"Radiologic examination of the neck/spine, 2-3 views",4299350,CDM,320,RC,72040,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
"Radiologic examination of the neck/spine, 4-5 views",4299352,CDM,320,RC,72050,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
"Radiologic examination of the middle spine, 2 views",4299354,CDM,320,RC,72070,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
X-ray of the lower spine 2-3 views,4299356,CDM,320,RC,72100,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
"X-ray of lower and sacral spine, minimum of 4 views",4299358,CDM,320,RC,72110,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
SACRUM/COCCYX MIN 2 VWS,4299360,CDM,320,RC,72220,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the pelvis,4299362,CDM,320,RC,72170,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
HIPS (2V) LEFT,4299364,CDM,320,RC,73510,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
HIPS (2V) RIGHT,4299364RT,CDM,320,RC,73510,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
Radiologic examination of the finger(s),4299366,CDM,320,RC,73140,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the finger(s),4299366RT,CDM,320,RC,73140,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
X-ray of the hand with 2 views,4299368,CDM,320,RC,73120,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
X-ray of the hand with 2 views,4299368RT,CDM,320,RC,73120,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,364,
Up to 3 views,4299370,CDM,320,RC,73110,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Up to 3 views,4299370RT,CDM,320,RC,73110,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the forearm,4299372,CDM,320,RC,73090,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the forearm,4299372RT,CDM,320,RC,73090,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
"Radiologic examination, elbow; 3 or more views",4299374,CDM,320,RC,73080,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
"Radiologic examination, elbow; 3 or more views",4299374RT,CDM,320,RC,73080,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
HUMERUS MIN 2 VIEWS LEFT,4299376,CDM,320,RC,73060,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
HUMERUS MIN 2 VIEWS RIGHT,4299376RT,CDM,320,RC,73060,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the shoulder,4299378,CDM,320,RC,73030,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the shoulder,4299378RT,CDM,320,RC,73030,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the collar bone,4299380,CDM,320,RC,73000,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the collar bone,4299380RT,CDM,320,RC,73000,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the foot with 3 or more views,4299382,CDM,320,RC,73630,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the foot with 3 or more views,4299382RT,CDM,320,RC,73630,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the ankle with 3 views,4299384,CDM,320,RC,73610,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the ankle with 3 views,4299384RT,CDM,320,RC,73610,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the lower leg,4299386,CDM,320,RC,73590,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the lower leg,4299386RT,CDM,320,RC,73590,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the knee with 1 or 2 views,4299388,CDM,320,RC,73560,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the knee with 1 or 2 views,4299388RT,CDM,320,RC,73560,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
KNEE COMPLETE LEFT,4299390,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
FEMUR 2 VIEWS LEFT,4299392,CDM,320,RC,73550,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
FEMUR 2 VIEWS RIGHT,4299392RT,CDM,320,RC,73550,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,364,
IM - SELLA TURCICA,4299394,CDM,320,RC,70240,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the ankle with 2 views,4299442,CDM,320,RC,73600,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
Radiologic examination of the ankle with 2 views,4299442RT,CDM,320,RC,73600,HCPCS,Outpatient,,,,,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,364,
MISC,4300001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
MISC IV,4300002,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
ALBUTEROL HFA 8GM INHALER,4300003,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTOBARBITAL 2500MG 50ML,4300006,CDM,636,RC,J2515,HCPCS,Outpatient,,,0.01,0.01,,120.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,34.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,61.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.35,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,78.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,120.71,
FOSINOPRIL 10MG TAB,4300007,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTRIAXONE 250MG VIAL,4300009,CDM,636,RC,J0696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORT SODSUC 100MG VL,4300010,CDM,636,RC,J1720,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 1MG/ML PEDI,4300011,CDM,636,RC,J1720,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 250MG VIAL,4300012,CDM,636,RC,J1720,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUMAZENIL .1MG/ML,4300013,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORT SODSUC 500MG VL,4300014,CDM,636,RC,J1720,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 10% 500MG (50ML),4300015,CDM,636,RC,J1561,HCPCS,Outpatient,,,0.01,0.01,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,174.38,
METHYLPRED SODSUC 500MGVL,4300018,CDM,636,RC,J2930,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIMOLOL .25% GEL 5ML,4300019,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPRED SODSUC 1GM VL,4300020,CDM,636,RC,J2930,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPRED SODSUC 40MG VL,4300022,CDM,636,RC,J2920,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXIL 1MG INJ (1064MG),4300023,CDM,636,RC,J1944,HCPCS,Outpatient,,,0.01,0.01,,11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11,
RISPERIDONE 1MG TABLET,4300025,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHYTONADIONE 5MG TAB,4300026,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GABAPENTIN 100 MG CAP UD,4300027,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SACITUZUMAB GOVITECAN-HZIY 2.5MG (180MG),4300029,CDM,636,RC,J9317,HCPCS,Outpatient,,,0.01,0.01,,117.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,33.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,59.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,76.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,117.74,
CLARITHROMYCIN 250MG TAB,4300031,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AQUAPHOR 1.75OZ.,4300032,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAMETH VAL 0.1% 15GM OINT,4300035,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MODAFINIL 100MG TABS,4300037,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN 120MG SUPP,4300038,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN 325MG SUPP,4300040,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE HEXACETONIDE 5MG INJ,4300041,CDM,636,RC,J3303,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN 650MG SUPP,4300042,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMIN 160MG 5ML 5ML EL,4300044,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINO 325MG 10.15ML,4300046,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARBONATE 50MEQ,4300047,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACITRACIN 0.9GM,4300048,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN 500MG TABUD,4300050,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GRANISETRON 100 MCG,4300051,CDM,636,RC,J1626,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETOMINOPHENW/ COD 5ML,4300053,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN POWDER 1.2 GM,4300054,CDM,636,RC,J3260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXIL 1MG INJ (441MG) FD,4300055,CDM,636,RC,J1944,HCPCS,Outpatient,,,0.01,0.01,,11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11,
DIGOXIN IMMUNE FAB,4300059,CDM,636,RC,J1162,HCPCS,Outpatient,,,0.01,0.01,,16261.23,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4593.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,8268.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16077.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,10565.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,4593.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,16261.23,
DORNASE ALFA 2.5MG INH,4300060,CDM,636,RC,J7639,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
APRACLONIDINE 1% .1ML,4300065,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXIL 1MG INJ (441MG),4300068,CDM,636,RC,J1944,HCPCS,Outpatient,,,0.01,0.01,,11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11,
IPRATROP  02  2 5 ML UD,4300069,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE 7.5MG INJ **PNT ASSIST**,4300072,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
CARDIO GREEN 25MG AMP,4300074,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXIL 1MG INJ (662MG),4300075,CDM,636,RC,J1944,HCPCS,Outpatient,,,0.01,0.01,,11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11,
FOSCARNET 24MG/ML 250ML,4300076,CDM,636,RC,J1455,HCPCS,Outpatient,,,0.01,0.01,,209.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,59.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,106.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.74,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.07,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,209.1,
CALCITRIOL 1MCG/ML 1ML AMP,4300077,CDM,636,RC,J0636,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS SULFATE ORAL 5ML,4300084,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACLOFEN 10MG (20ML) INTRATHECAL KIT,4300088,CDM,636,RC,J0475,HCPCS,Outpatient,,,0.01,0.01,,645.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,182.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,328.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.91,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,419.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,645.2,
LIDOCAINE HCL 20MG/ML 5ML,4300091,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACTIVATED CHAR 25GM/120ML,4300094,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOROLAC 10MG TABLET,4300096,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM CD 300 MG CAP,4300097,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXIL 1MG INJ (882MG),4300098,CDM,636,RC,J1944,HCPCS,Outpatient,,,0.01,0.01,,11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11,
SODIUM CHLORIDE 23.4% (4MEQ/ML) 100ML,4300102,CDM,250,RC,J7131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMVASTATIN 10MG UD TABLE,4300103,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOBUTAMINE BAG 250MG (1000MG/250ML) IV,4300104,CDM,636,RC,J1250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SERTRALINE 50 MG TABLET,4300105,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE MONONITRATE 20,4300107,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TESTOSTERONE CYP 200MG/ML **PT OWN MED**,4300108,CDM,636,RC,J1071,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ORAJEL MOUTH AID GEL,4300115,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOIN SWABSTICK,4300117,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IDARUBICIN 5MG INJECTION,4300120,CDM,636,RC,J9211,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PSEUDOEPHEDR/TRIPROL TAB,4300122,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMIL SR 120MG TABLET,4300123,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETODOLAC 200MG CAPSULE,4300126,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE ACETETATE 3.75MG (LUPRON),4300128,CDM,636,RC,J1950,HCPCS,Outpatient,,,0.01,0.01,,5396.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2743.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5335.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3505.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5396.16,
METOPROLOL XL 50MG TABLET,4300131,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 200MG TAB UD,4300134,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INFED 100MG/2ML,4300135,CDM,636,RC,J1750,HCPCS,Outpatient,,,0.01,0.01,,61.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,31.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60.93,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,40.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,17.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,61.63,
CARBAMAZEPINE 100MG/5ML,4300137,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADRENALIN CL NASAL 30ML,4300138,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYBURIDE 3MG MICRO TAB,4300142,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN HCL 10MG INJ,4300148,CDM,636,RC,J9000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN HCL 50MG/ 25ML VIAL,4300150,CDM,636,RC,J9000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN 250MG TAB,4300153,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD CHLORIDE 5% 15ML GTTS,4300154,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 200MG TABLET,4300158,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOXETINE 20MG/5ML,4300160,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPROXEN EC 375MG TAB,4300162,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXILSUBMICR1MGINJ(675MG,4300163,CDM,636,RC,J1943,HCPCS,Outpatient,,,0.01,0.01,,10.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.67,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.79,
CAFFEINE CIT 600MG/30ML,4300164,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYMETAZOLINE 0.05% NASAL SPY 30ML-IP,4300165,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE SULF 60MG SA,4300166,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GABAPENTIN 300 MG CAP UD,4300167,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOPROSTENOL 1.5MG VIAL,4300170,CDM,636,RC,J1325,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STERILE DILUENT FOR EPOPROSTENOL 50ML,4300171,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYMETAZOLINE 0.05% NASAL SPY 15ML-IP,4300172,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINEZOLID 100MG/5ML 150ML,4300173,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 11MG TAB,4300176,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN LIPOSOM 50 MG,4300177,CDM,636,RC,Q2050,HCPCS,Outpatient,,,0.01,0.01,,512.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,260.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,333.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,512.76,
ADENOSINE 3MG/ML DIAGNOSTIC INJECTION,4300179,CDM,636,RC,J0153,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICARDIPINE 2.5MG/ML 10ML,4300180,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREGABALIN 300MG CAP,4300181,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"HEPARIN 1,000U/ML 30ML VIAL",4300182,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOFLOXACIN 750MG PB,4300183,CDM,636,RC,J1956,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOFLOXACIN 500MG PB,4300184,CDM,636,RC,J1956,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOFLOXACIN 500 MG TAB,4300186,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOPROSTENOL 0.5MG VIAL,4300187,CDM,636,RC,J1325,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRASUGREL HCL 10MG TAB,4300190,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFACET/PREDN .25% 5ML,4300192,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRASUGREL HCL 5MG TAB,4300193,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIVALPROEX 125MG SPRINKLE,4300200,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBOPLATIN 150MG/15ML VL,4300202,CDM,636,RC,J9045,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBOPLATIN 450MG/45ML VL,4300203,CDM,636,RC,J9045,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 13MG TABLET,4300205,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAI W/EPI 2% 10ML MPF,4300206,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PACLITAXEL 300MG/50ML INJ,4300209,CDM,636,RC,J9267,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PACLITAXEL 100MG/16.7ML V,4300210,CDM,636,RC,J9267,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MULTITRACE NEONATAL 2ML,4300215,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANTITHROMBIN III 1 IU (500 IU VIAL) INJ,4300216,CDM,636,RC,J7197,HCPCS,Outpatient,,,0.01,0.01,,13.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,6.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.98,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3.71,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,13.13,
OMNIPAQUE 300 50ML INJ,4300218,CDM,636,RC,Q9967,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 15ML,4300220,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPHENIDATE SR 20MG,4300223,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MULTIVITAMIN PED 5ML,4300225,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXCARBAZEPINE  300MG TAB,4300226,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PED TRACE ELEMENTS,4300227,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTACAN 20MG INJ,4300228,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMNIPAQUE 240 10ML INJ,4300231,CDM,636,RC,Q9966,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIDOFOVIR 75MG/ML 5ML,4300233,CDM,636,RC,J0740,HCPCS,Outpatient,,,0.01,0.01,,1948.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,550.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,990.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1926.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1265.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,550.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1948.34,
SPIRONOLAC 25MGTABLET U/D,4300234,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACLOFEN INTRATHECAL 40MG,4300235,CDM,636,RC,J0475,HCPCS,Outpatient,,,0.01,0.01,,645.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,182.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,328.06,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,637.91,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,419.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,182.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,645.2,
SPIRONOLACTO 50MG TAB U/D,4300236,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SARNA LOTION 222ML,4300237,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALEMTUZUMAB 30MG INJ (1ML) FD,4300238,CDM,636,RC,J0202,HCPCS,Outpatient,,,0.01,0.01,,8116.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2292.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4126.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8024.69,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,5273.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2292.77,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8116.4,
TERIPARATIDE 600MCG/2.4ML,4300239,CDM,636,RC,J3110,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE ER 200MG CAP,4300240,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ABACAVIR 300MG TAB,4300241,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPARACAIN 0.5% OPT 15ML,4300243,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS/VITC 125/200 TAB,4300244,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 5UNIT/5ML SYRINGE,4300247,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUDESONIDE 90MCG FLXHLR,4300249,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLDOPA 250MG TAB U/D,4300250,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB 10MG (100MG) INJ,4300251,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
METHYLDOPA  500MG TAB U/D,4300252,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PANTOPRAZOLE 40MG INJ,4300253,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 1MG/ML 5ML LIQ,4300255,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB-AWWB 10MG INJ (100MG/4M,4300256,CDM,636,RC,Q5107,HCPCS,Outpatient,,,0.01,0.01,,98.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.47,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.58,
OFATUMUMAB 10MG INJ (1000MG VIAL),4300258,CDM,636,RC,J9302,HCPCS,Outpatient,,,0.01,0.01,,226.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,63.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,115.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.86,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,147.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,226.41,
FILGRASTIM 480MCG/1.6ML,4300259,CDM,636,RC,J1442,HCPCS,Outpatient,,,0.01,0.01,,3.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3.5,
DEXMETHYLPHENIDATE 10MG T,4300261,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVAFLOXIN 250MG TABLET,4300264,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 12MG TABLET,4300265,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DRONEDARONE 400MG TABLET,4300267,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CASPOFUNGIN 50MG VIAL,4300268,CDM,636,RC,J0637,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PANTOPRAZOLE 40MG DR SUSP,4300271,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB-AWWB 10MG INJ (400MG/16ML),4300272,CDM,636,RC,Q5107,HCPCS,Outpatient,,,0.01,0.01,,98.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.47,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.58,
BUPROPION 150MG SR TABLET,4300274,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUMATRIPTAN SUC. 50MG TAB,4300278,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUMATRIPTAN SUC 100MG TAB,4300279,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BOSENTAN 62.5MG TAB,4300280,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALSARTAN 80MG,4300281,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALSARTAN 40MG TAB,4300282,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CETUXIMAB 10MG (200MG) INJ,4300283,CDM,636,RC,J9055,HCPCS,Outpatient,,,0.01,0.01,,255.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,130.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.98,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,166.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,255.87,
VALSARTAN 160MG TAB,4300284,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBOPLATIN 50MG INJ,4300285,CDM,636,RC,J9045,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPHOSPHAMIDE 500MG VL,4300287,CDM,636,RC,J9070,HCPCS,Outpatient,,,0.01,0.01,,63.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,32.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.79,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,63.5,
CLARITHROMYCIN 125/5 50ML,4300290,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SEVELAMER CARB 800MG TAB,4300292,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTRIAXONE 20MG/ML NSY,4300293,CDM,636,RC,J0696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PACLITAXEL PROTEIN-BOUND 1MG,4300294,CDM,636,RC,J9264,HCPCS,Outpatient,,,0.01,0.01,,52.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,26.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,34.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,52.35,
PANITUMUMAB 100MG VIAL,4300295,CDM,636,RC,J9303,HCPCS,Outpatient,,,0.01,0.01,,530,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,149.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,269.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,344.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,530,
PANITUMUMAB 400MG VIAL,4300296,CDM,636,RC,J9303,HCPCS,Outpatient,,,0.01,0.01,,530,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,149.72,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,269.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,524.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,344.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,149.72,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,530,
KETOROLAC 0.5% OPHT 5ML,4300298,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALONOSETRON .25MG/5ML VL,4300301,CDM,636,RC,J2469,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBEPOETIN ALFA 1 MCG (500MCG) INJ,4300302,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
DARBEPOETIN ALFA 1 MCG (100MCG) INJ,4300303,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
DARBEPOETIN ALFA 1 MCG (200MCG) INJ,4300304,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
CISPLATIN 10MG (100MG),4300305,CDM,636,RC,J9060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"VITAMIN A 10,000U CAP",4300307,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIDOVUDINE 50MG/5ML SYRUP,4300309,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIDOVUDINE 10MG/ML,4300310,CDM,636,RC,J3485,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPHOSPHAMIDE 2GM VL,4300311,CDM,636,RC,J9070,HCPCS,Outpatient,,,0.01,0.01,,63.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,32.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.79,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,63.5,
DOXORUBICIN 200MG/100ML VL,4300312,CDM,636,RC,J9000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FULVESTRANT 250MG PF INJ,4300313,CDM,636,RC,J9395,HCPCS,Outpatient,,,0.01,0.01,,29.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,15.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.26,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,8.36,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,29.59,
DOCETAXEL 160MG INJ,4300316,CDM,636,RC,J9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUCOVORIN 200MG INJ,4300318,CDM,636,RC,J0640,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INTERFERON ALFA-2B 10MIU,4300319,CDM,636,RC,J9214,HCPCS,Outpatient,,,0.01,0.01,,115.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.99,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,74.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.29,
HEPARIN 100UNIT/ML 5ML FLUSH,4300321,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUCOVORIN 350MG INJ,4300325,CDM,636,RC,J0640,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUCOVORIN 500MG INJ,4300326,CDM,636,RC,J0640,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROMIPLASTIN 250MCG INJ,4300327,CDM,636,RC,J2796,HCPCS,Outpatient,,,0.01,0.01,,338.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.12,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,220.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.95,
OXALIPLATIN 50MG INJ,4300328,CDM,636,RC,J9263,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE 2% CREAM 3.3OZ,4300329,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETOPOSIDE 10MG/0.5ML INJ (50ML),4300335,CDM,636,RC,J9181,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENDAMUSTINE 1MG (100MG)  INJ,4300336,CDM,636,RC,J9033,HCPCS,Outpatient,,,0.01,0.01,,40.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,20.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,40.42,
BENDAMUSTINE 1MG (25MG) INJ,4300337,CDM,636,RC,J9033,HCPCS,Outpatient,,,0.01,0.01,,40.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,20.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,40.42,
ZOLEDRONIC ACID 5MG RECLA,4300338,CDM,636,RC,J3489,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCTREOTIDE ACE. 20MG KIT,4300339,CDM,636,RC,J2353,HCPCS,Outpatient,,,0.01,0.01,,733.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,207.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,372.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,725.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,476.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,733.34,
STERILE WATER 50ML VIAL,4300340,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VINBLASTINE 10MG VIAL,4300341,CDM,636,RC,J9360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON 2MG/ML 20ML,4300342,CDM,636,RC,J2405,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON 32MG/50ML BAG,4300343,CDM,636,RC,J2405,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBEPOETIN ALFA 1 MCG (300MCG) INJ,4300344,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
FONDAPARINUX 7.5MG SYRING,4300345,CDM,636,RC,J1652,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPIRUBICIN 50MG/25ML VIAL,4300346,CDM,636,RC,J9178,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZ/BEN ACID 20/0.1 30GM,4300348,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOLASETRON 100MG/5ML VL,4300349,CDM,636,RC,J1260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE 0.4MG/ML VIAL,4300350,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBOPLATIN 600MG/60ML VL,4300352,CDM,636,RC,J9045,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUCOVORIN 100MG VIAL,4300353,CDM,636,RC,J0640,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MITOMYCIN 20MG VIAL,4300354,CDM,636,RC,J9280,HCPCS,Outpatient,,,0.01,0.01,,338.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,219.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.45,
AMINOCAPR ACID 500MG TAB,4300356,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MITOXANTRONE 20MG/10ML VL,4300357,CDM,636,RC,J9293,HCPCS,Outpatient,,,0.01,0.01,,146.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,41.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,74.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144.86,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,95.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,146.52,
INTERFERON ALFA 50MM UNIT,4300359,CDM,636,RC,J9214,HCPCS,Outpatient,,,0.01,0.01,,115.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.99,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,74.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.29,
DONEPEZIL 5MG TABLET,4300360,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DONEPEZIL 10MG TAB,4300361,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETOMIDATE 2MG/ML 10ML VL,4300362,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIKA SULF 250MG/ML 4ML V,4300364,CDM,636,RC,J0278,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IDARUBICIN HCL 10MG/10ML,4300365,CDM,636,RC,J9211,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOETIN ALFA 1000 UNITS,4300367,CDM,636,RC,J0885,HCPCS,Outpatient,,,0.01,0.01,,25.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.09,
"EPOETIN ALFA 40,000 UNITS",4300368,CDM,636,RC,J0885,HCPCS,Outpatient,,,0.01,0.01,,25.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.09,
BUPROPION SR 100 MG TAB,4300369,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPENTOLATE 0.5% OPTH,4300371,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMINOCAPROI ACID 20ML VIA,4300372,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MESNA 1000MG VIAL,4300373,CDM,636,RC,J9209,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETOPOSIDE 10MG/0.5ML INJ (5ML),4300374,CDM,636,RC,J9181,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ABATACEPT 10MG INJ,4300375,CDM,636,RC,J0129,HCPCS,Outpatient,,,0.01,0.01,,151.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,76.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.44,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,151.15,
CERTOLIZUMAB PEGOL 1MG,4300376,CDM,636,RC,J0717,HCPCS,Outpatient,,,0.01,0.01,,17.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,8.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.14,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,11.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,17.34,
SILDENAFIL 2.5MG/ML 40ML,4300377,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN 900MG/6ML VL,4300379,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WATER FOR INJECTION 20ML,4300380,CDM,250,RC,A4216,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RHO(D) IMM GLOB 15000 IU,4300382,CDM,636,RC,J2792,HCPCS,Outpatient,,,0.01,0.01,,118.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,60.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,118.44,
AMINOP 250MG/10ML 10ML VL,4300384,CDM,636,RC,J0280,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE 50MG/1ML VIAL,4300385,CDM,636,RC,J3410,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMINOPHYLLINE 500MG INJ,4300386,CDM,636,RC,J0280,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MILNACIPRAN HCL 25 MG TAB,4300387,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMMONIA INHALER,4300388,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLYETHYLENE GLYCOL 238GM,4300389,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TAPENTADOL HCL 75MG TAB,4300391,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCTREOTIDE LAR 30MG KIT,4300393,CDM,636,RC,J2353,HCPCS,Outpatient,,,0.01,0.01,,733.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,207.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,372.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,725.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,476.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,207.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,733.34,
SAXAGLIPTIN HCL 5 MG TAB,4300394,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CETIRIZINE 10MG TABLET,4300396,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOCILIZUMAB 1MG INJ (200MG VIAL),4300397,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
ETOMIDATE 2MG/ML 20ML VL,4300398,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENDAMUSTINE 1MG (100MG) MDV (BENDEKA),4300402,CDM,636,RC,J9034,HCPCS,Outpatient,,,0.01,0.01,,56.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,28.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.51,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,36.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,56.14,
IRON SUCROSE 1MG INJ (200MG/10ML),4300403,CDM,636,RC,J1756,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEROPENEM 20 MG/ML INJ PEDI,4300404,CDM,636,RC,J2185,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 1MG (0.2MG/ML) INJ,4300415,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 1MG (0.5MG/ML) INJ,4300416,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 0.1MG (10MCG/ML) INJ,4300417,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 0.1MG (5MCG/ML) INJ,4300418,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 20MG (2MG/ML) INJ,4300419,CDM,636,RC,J1940,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDRALAZINE 20MG (1MG/ML) INJ,4300420,CDM,636,RC,J0360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN-REGULAR 5UNITS (1 UNIT/ML) INJ,4300421,CDM,636,RC,J1815,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 2MG (0.4MG/ML) INJ,4300422,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 10MG (0.5MG/ML) INJ,4300423,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBU HYDRO 320MG/5ML 30ML,4300424,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCUSATE SODIUM 5ML ENEMA,4300425,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPINASTINE 0.05% 6ML OPHTH DROPS,4300427,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VECURONIUM 10MG (0.4 MG/ML) INJ,4300429,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDODRINE 5MG TAB,4300430,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERTAPENEM (PEDIATRIC) 20MG/ML PB,4300431,CDM,636,RC,J1335,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYLAN G-F 20 1MG (48MG/6ML) SYR,4300432,CDM,636,RC,J7325,HCPCS,Outpatient,,,0.01,0.01,,31.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,15.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.69,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,20.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,31.04,
PENTAMIDINE 300MG INJ,4300433,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 2MG/ML 10ML,4300444,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN BIOSIMILAR 1000 UNIT (2,000IU) V",4300447,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
"EPOETIN BIOSIMILAR 1000 UNIT (3,000IU) V",4300448,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
"EPOETIN BIOSIMILAR 1000 UNIT (4,000IU) V",4300449,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
NAPROXEN SOD 275MG TAB UD,4300450,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OLOPATADINE 0.1% OPH 5ML,4300457,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 1 GM INJECTION,4300458,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 500MG INJECTION,4300462,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REMIFENTANIL 2MG VIAL,4300463,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REMIFENTANIL PCA 1MG/25ML,4300464,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETOPOSIDE 10MG/0.5ML INJ (25ML),4300468,CDM,636,RC,J9181,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDO HYDRO 2% 15ML SOLN,4300474,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VINORELBINE 10 MG INJ.,4300477,CDM,636,RC,J9390,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHYSOSTIGMINE  1MG/ML AMP,4300490,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUTALBITAL/ASA/CAFF 50/325/40MG CAPSULE,4300491,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBIDOPA/LEVA 25/100 ER,4300498,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MECLIZINE 25MG TABLET UD,4300502,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACLIDINIUM 400MCG PWD FOR INHAL (60),4300507,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
UMECLIDINIUM 62MCG INHAL PWD (7),4300511,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCTOZONE-HC 30GM CRM,4300512,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TUBERCULIN PPD 5TU/0.1ML,4300515,CDM,250,RC,,,Outpatient,,,31,18.6,,,,,,Other,Not Separately reimbursable,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.5,50,,,percent of total billed charges,pays at 50% of total billed charges,21.7,70,,,percent of total billed charges,70% of total billed charges,23.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,27.9,
PPD TB INTRADERMAL TEST,4300515,CDM,302,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
TUBERCULIN PPD 5TU/0.1ML,4300516,CDM,250,RC,,,Outpatient,,,31,18.6,,,,,,Other,Not Separately reimbursable,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.5,50,,,percent of total billed charges,pays at 50% of total billed charges,21.7,70,,,percent of total billed charges,70% of total billed charges,23.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,24.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,27.9,
HYDRALAZINE 20MG/ML VIAL,4300526,CDM,636,RC,J0360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDRALAZINE 25MG TAB UD,4300538,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROMOSOZUMAB 210MG (2 SYR=105MG EA),4300539,CDM,636,RC,J3111,HCPCS,Outpatient,,,0.01,0.01,,36.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,10.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,18.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.22,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,23.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,36.63,
HYDRALAZINE 50MG TAB UD,4300540,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHYTONADIONE 1MG/0.5ML INJ,4300546,CDM,636,RC,J3430,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHYTONADIONE 10MG/ML AMP,4300548,CDM,636,RC,J3430,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIDOVUDINE 300MG TABLET,4300555,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ELOTUZUMAB 1MG INJ 300MG VIAL,4300556,CDM,636,RC,J9176,HCPCS,Outpatient,,,0.01,0.01,,25.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.55,
ELOTUZUMAB 1MG INJ 400MG VIAL,4300557,CDM,636,RC,J9176,HCPCS,Outpatient,,,0.01,0.01,,25.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.55,
MINE OIL/PETRO 454GM OINT,4300558,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIDOVUDINE PEDI 4 MG/ML 5 ML IV,4300559,CDM,636,RC,J3485,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALPROATE 500MG 5ML VIAL,4300569,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN E 50U/ML DROPS,4300572,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE SULFATE 100MG,4300573,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE 40MG/ML 5ML,4300618,CDM,636,RC,J3301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCI ACET .5% 15GM OINT,4300626,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE 0.1% CR 15G,4300642,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCI ACET .1% 15GM OIN,4300648,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROTRIPTYLINE 5MG TABLET,4300665,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN E 200U CAPSULE,4300667,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GABAPENTIN 250MG/5ML ORAL SOLN,4300671,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPHETAMINE MIXTURES 10MG,4300675,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NALTREXONE 50MG TABLET,4300677,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIHEXYPHENIDYL HCL 2MG,4300680,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIHEXYPHENIDYL 5MG TAB,4300682,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASCORBIC ACID 250MG TABUD,4300698,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASCORBIC ACID 500MG TABUD,4300700,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASPIRIN/BUFFERS 325MG TAB,4300704,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRIL SUSP 1MG/ML (1ML),4300706,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMOTIDINE SOLN 8MG/ML,4300707,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISINOPRIL SUSP 1MG/ML (ML),4300709,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXAPINE 100MG TAB,4300711,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOPROLOL SUSP 10MG/ML (1ML),4300712,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INFLIXMAB-ABDA  10MG (100MG) VIAL,4300713,CDM,636,RC,Q5104,HCPCS,Outpatient,,,0.01,0.01,,115.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,74.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,32.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.26,
URSODIOL SUSP 25MG/ML (1ML),4300714,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALLOPURINOL SUSP 20 MG/ML (1ML),4300715,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAZOLAMIDE SUSP 25MG/ML (1ML),4300716,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE LAUROXIL 1MG INJ (675MG) FD,4300717,CDM,636,RC,J1943,HCPCS,Outpatient,,,0.01,0.01,,10.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.67,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.79,
ARIPIPRAZOLE LAUROXIL 1MG INJ (1064MG)FD,4300718,CDM,636,RC,J1943,HCPCS,Outpatient,,,0.01,0.01,,10.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.67,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.79,
ARIPIPRAZOLE LAUROXIL 1MG INJ (882MG)FD,4300719,CDM,636,RC,J1943,HCPCS,Outpatient,,,0.01,0.01,,10.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.67,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.79,
ARIPIPRAZOLE LAUROXIL 1MG INJ (662MG)FD,4300720,CDM,636,RC,J1943,HCPCS,Outpatient,,,0.01,0.01,,10.79,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.67,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.79,
LOSARTAN SUSP 2.5MG/ML (1ML),4300721,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASPIRIN 325MG TAB EC UD,4300737,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASPIRIN 300MG SUPP,4300744,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASPIRIN 600MG SUPP,4300746,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASPIRIN 325MG TABLET UD,4300748,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"BOWEL PREP KIT (NA, K, MG ORAL SOLN)",4300749,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FILGRASTIM 1MCG (480MCG/ 0.8ML) SYRINGE,4300750,CDM,636,RC,J1442,HCPCS,Outpatient,,,0.01,0.01,,3.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3.5,
HYDROXYZINE 10MG/5ML UD,4300756,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE 10MG TAB,4300766,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE HCL 25MG TAB,4300768,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE HCL 50MG TAB,4300770,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM .5MG TABLET U/D,4300780,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORATADINE 10MG TABLET,4300781,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 1MG TABLET U/D,4300782,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 2MG TABLET U/D,4300784,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIZATIDINE 300MG CAP,4300785,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 4MG/ML 1ML VIAL,4300790,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 2MG/ML 1ML VIAL,4300792,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALCINONIDE 0.1% CREAM 30GM,4300793,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALCINONIDE 0.1% OINTMENT 30GM,4300794,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOBETASOL PROP OINT,4300799,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE 0.1MG/ML 5ML SYR,4300812,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE SULF 0.25MG/5ML,4300813,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IDARUCIZUMAB 2.5 GRAMS/50ML VIAL,4300814,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE 1MG/ML 1ML VIAL,4300820,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE 1% OPHTH SOLN 5ML,4300825,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE SULF 1% 3.5GM OI,4300826,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPIN SULF 1% 2ML DROPS,4300828,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPRATROP HFA 12.9GM INH,4300833,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOX/K CLAV 250MG TAB U/D,4300846,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOX/K CLAV 500MG TAB U/D,4300848,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHONDR/HYALUR 40-17MG/1ML,4300852,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICROFIBR COLLA 70 35 1MM,4300880,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZTREONAM 2GM VIAL,4300887,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
B & O SUPP 15A,4300906,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
B & O 16A SUPP,4300908,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"BACITRACIN 50,000 U VIAL",4300910,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACITRAC 500U/GM 15GM OIN,4300916,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACITRA 500U/GM 3.75GM OI,4300924,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASPIRIN 81MG TAB CHEW,4300948,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANALGESIC OINT 30GM,4300966,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYL SALICYLATE-MENTHOL CREAM 57GM,4300967,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYL SALICYLATE-MENTHOL CREAM 85 GM,4300968,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDR HCL 2% 30GM CR,4300971,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDRAMINE 50MG UD,4300976,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDRAMINE 25MG UD,4300982,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDRAMINE12.5MG/5ML,4300984,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROBENECID 500MG TAB U/D,4300990,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BICALUTAMIDE 50MG TABLET,4300991,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIRTAZAPINE 30MG TABLET,4300992,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICYCL HCL 10MG/ML 2ML AM,4300994,CDM,636,RC,J0500,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CASIRIVIMAB/IMDEVIMAB 600MG/600MG INJ FD,4300995,CDM,636,RC,Q0243,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (MODERNA) 3,4300996,CDM,771,RC,0013A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
ADMIN IMMUNIZ COVID-19 DOSE (MODERNA) 2,4300997,CDM,771,RC,0012A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
ADMIN IMMUNIZ COVID-19 DOSE (MODERNA) 1,4300998,CDM,771,RC,0011A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
DICYCLOMINE SYRP 10MG/5ML,4300999,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (PFIZER) 1,4301001,CDM,771,RC,0001A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
PROGESTERONE 100MG CAP,4301002,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (PFIZER) 2,4301003,CDM,771,RC,0002A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
DICYCLOMINE 10MG CAP U/D,4301004,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE 3 (PFIZER),4301005,CDM,771,RC,0003A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
DICYCLOMINE 20MG TAB U/D,4301006,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANTIVENIN LATRODECTUS MAC,4301007,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLOROPROCAINE 2% 20ML INJ,4301009,CDM,636,RC,J2400,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERMETHRIN 1% 20Z RINSE,4301010,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORATADINE/PSEUDO TAB,4301011,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TORSEMIDE 20MG TABLET,4301013,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN 100MG\4ML SUSP,4301015,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (MODERNA) 1,4301016,CDM,771,RC,0011A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
COVID-19 VAC 100MCG/0.5ML(MODERNA),4301016,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEFLUNOMIDE 20MG TAB,4301017,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COVID-19 VAC 100MCG/0.5ML(MODERNA),4301019,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (MODERNA) 3,4301019,CDM,771,RC,0013A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
SALMETEROL XINAFOATE DISK,4301042,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REPAGLINIDE 0.5MG TAB,4301044,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERAMPANEL 10MG TABLET,4301045,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COLISTIMETHATE 150 MG/2 ML SOLN,4301055,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POVIDONE-IODINE OINT 1GM PACKET,4301058,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POVIDO-IODIN 10% 30GM OINT,4301059,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FINASTERIDE 5MG TAB UD,4301060,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETHANECHOL CL 10MG TAB U,4301063,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETHANECHOL CL 25MG TABUD,4301065,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DUTASTERIDE 0.5MG GELCAP,4301066,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOBUN HCL .5% 5ML  GTTS,4301069,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAXOLO HCL .5% 5ML GTT,4301100,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSOPRAZOLE 3MG/ML SUSP 90ML KIT,4301101,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEN G PROC/BENZ 1.2MU/2ML,4301106,CDM,636,RC,J0558,HCPCS,Outpatient,,,0.01,0.01,,55.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,28.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,36.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,15.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,55.71,
AZITHROMYCIN 100MG/5ML,4301107,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOTAXIME 20MG/ML 16.7ML,4301109,CDM,636,RC,J0698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CISATRACURIUM 20MG/10ML,4301111,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENG BENZ 600KU/ 1ML,4301112,CDM,636,RC,J0561,HCPCS,Outpatient,,,0.01,0.01,,71.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,36.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,71.36,
PENG BENZ 1.2MU/2ML,4301114,CDM,636,RC,J0561,HCPCS,Outpatient,,,0.01,0.01,,71.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,36.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,71.36,
PENG BENZ 2.4MU/4ML,4301116,CDM,636,RC,J0561,HCPCS,Outpatient,,,0.01,0.01,,71.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,36.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,71.36,
BICITRA 15ML,4301120,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BICITRA 30ML,4301121,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISACODYL 10MG SUPP,4301134,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISACODYL 10MG MAGIC SUPP,4301135,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISACODYL 5MG TABLET UD,4301136,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BLEOMYCIN 15 UNITS (15UNITS) INJ,4301138,CDM,636,RC,J9040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIOTROPIUM 18MCG/CP 5CP,4301142,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIMOLOL GFS 0.5% 5ML,4301145,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIOGLITAZONE 15MG TAB,4301158,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINOLONE 0.025% OINTMENT 15GM,4301160,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUTORPHANOL 4MG/ML 2ML VIAL,4301189,CDM,636,RC,J0595,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERBUT SULF 1MG/ML 1ML VL,4301190,CDM,636,RC,J3105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFACET/PRED 10% 0.23% OPHTH SOLN 10ML,4301192,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERBUT SULF 2.5MG TAB UD,4301194,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOMEPIZOLE 1.5G/1.5ML,4301210,CDM,636,RC,J1451,HCPCS,Outpatient,,,0.01,0.01,,23.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,15.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,23.39,
BSS 15ML SOLN,4301218,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BSS PLUS 500ML,4301222,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 4MG TABLET,4301225,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN ALFA 10,000 UNITS",4301226,CDM,636,RC,J0885,HCPCS,Outpatient,,,0.01,0.01,,25.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,7.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.09,
CLOFARABINE 20 MG/20 ML VIAL,4301230,CDM,636,RC,J9027,HCPCS,Outpatient,,,0.01,0.01,,82.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,41.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.51,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,53.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,82.44,
DURVALUMAB 10MG INJ (120MG),4301231,CDM,636,RC,J9173,HCPCS,Outpatient,,,0.01,0.01,,282.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,143.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.08,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,183.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,282.27,
BUMETANID .25MG/ML 2ML VL,4301234,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE .05%   16GM,4301236,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUDARABINE 50MG VIAL,4301238,CDM,636,RC,J9185,HCPCS,Outpatient,,,0.01,0.01,,1771.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,500.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,900.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1751.61,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1771.62,
BUMETANIDE 0.25MG/ML  4ML,4301239,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUMETANIDE .5MG TABLET UD,4301240,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUMETANIDE 1MG TABLET U/D,4301242,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUSPIRONE HCL 5MG TABLET,4301243,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUSPIRONE HCL 10MG TABLET,4301245,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ABCIXIMAB 10MG 5ML,4301248,CDM,636,RC,J0130,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 2MG/ML,4301251,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEFAZODONE 100 MG TABLET,4301252,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLIPIZIDE 5MG ER TAB,4301254,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRASTUZUMAB-ANNS 10MG INJ (150MG),4301255,CDM,636,RC,Q5117,HCPCS,Outpatient,,,0.01,0.01,,86.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,86.16,
METFORMIN 500 MG,4301257,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOEXIPRIL 7.5MG TAB,4301258,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAPAGLIFLOZIN 10MG TABLET,4301259,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLIPIZIDE 2.5MG ER TAB,4301260,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PILOCARPINE 5MG TAB,4301263,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRAMADOL 50MG TABLET,4301266,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIZANIDINE 4MG TABLET,4301267,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMCICLOVIR 500 MG TAB,4301268,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANREOTIDE ACETATE 120MG/0.5ML SYRNG,4301269,CDM,636,RC,J1930,HCPCS,Outpatient,,,0.01,0.01,,181.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,51.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,92.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,179.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,117.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,51.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,181.1,
Hepatitis A vaccination for adults,4301275,CDM,636,RC,90632,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZELASTINE NAS SPRY 137,4301276,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE SULFATE 20MG/ML,4301277,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAC-HYDRIN 12% LOT 225GM,4301279,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYSTEINE 50MG ML 10ML,4301280,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAFF/SOD BEN 250MG/ML 2ML,4301282,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FEXOFENADINE 60MG TAB UD,4301283,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAMOTRIGINE 25MG TABLET,4301284,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAMOTRIGINE 100MG TABLET,4301285,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOSPORINE 25MG CAPSULE,4301286,CDM,636,RC,J7515,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAPAGLIFLOZIN 5MG TABLET,4301287,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAMOXINE HCL/ZINC ACET,4301288,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INFLIXIMAB BIOSIMILAR 10MG INJ 100MG VL,4301289,CDM,636,RC,Q5103,HCPCS,Outpatient,,,0.01,0.01,,49.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,32.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,49.31,
AZITHROMYCIN 600MG TAB,4301290,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
A biologic medication,4301291,CDM,636,RC,J1745,HCPCS,Outpatient,,,0.01,0.01,,115.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.24,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,75.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.54,
CALAMINE ZINC LOTION,4301294,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIV-EPI W FENT 2MCG/ML ON-Q 100ML PROD,4301301,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INFLIXIMAB BIOSIMILAR 10MG INJ FD,4301303,CDM,636,RC,Q5103,HCPCS,Outpatient,,,0.01,0.01,,49.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,32.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,49.31,
A biologic medication,4301304,CDM,636,RC,J1745,HCPCS,Outpatient,,,0.01,0.01,,115.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.24,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,75.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.54,
CEFTAROLINE 600MG VIAL,4301305,CDM,636,RC,J0712,HCPCS,Outpatient,,,0.01,0.01,,13.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,6.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.51,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,13.66,
VERAPAMIL 5MG/2ML VIAL,4301306,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CHLORIDE 13.2GM,4301307,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMIL 2.5MG/ML 4ML,4301308,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMI HCL 240MG TAB ER,4301309,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DRONABINOL 2.5MG CAP,4301310,CDM,636,RC,Q0167,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMIL HCL 80MG TAB UD,4301312,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MYCOPHENOLATE 250.00 MG,4301313,CDM,636,RC,J7517,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMI HCL 120MG TAB UD,4301314,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIPERACILLIN/TAZOB 1125MG PEDI SYRINGE,4301315,CDM,636,RC,J2543,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ERGOCALCIFER 50,000IU TAB",4301318,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCITONI 400.00 IU/2ML,4301324,CDM,636,RC,J0630,HCPCS,Outpatient,,,0.01,0.01,,4589.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2333.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4537.25,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2981.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,4589.1,
CALCITONI 400.00 IU/2ML-EC,4301324,CDM,636,RC,J0630,HCPCS,Outpatient,,,,,,4589.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2333.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,4537.25,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2981.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.33,4589.1,
PORACTANT 80MG/ML 3ML,4301325,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 40MG/0.4ML SYR,4301335,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CL 10% 10ML VIAL,4301336,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLYETHYLENE 17GM,4301337,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CL 10% 10ML SYRINGE,4301338,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 1MG/ML SYRINGE (CSP),4301339,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 10MG/ML 5ML,4301340,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 120MG 0.8ML,4301343,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 100MG/ML 1ML,4301344,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 80MG/0.8ML,4301345,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM GLUC 500MG TAB UD,4301346,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 60MG 0.6ML,4301347,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM GLUC 10% 10ML VL,4301354,CDM,636,RC,J0610,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUGAMMADEX 200MG/2ML INJECTION,4301355,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERBINAFINE 250MG TAB,4301364,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NELFINAVIR 250MG CAP,4301366,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINEZOLID 600MG/300ML INJ,4301385,CDM,636,RC,J2020,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINEZOLID 200MG/100ML,4301386,CDM,636,RC,J2020,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CETYLPYRI CHL 30ML MOUTH WASH,4301387,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIVOLUMAB 1MG INJ 12ML FD,4301390,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
CAPTOPRIL 12.5MG TAB U/D,4301393,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHYTONADIONE 1MG/ML 5ML SUSP,4301394,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAPTOPRIL 25MG TAB U/D,4301396,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAPTOPRIL 50MG TAB,4301398,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAPTOPRIL 100MG TAB,4301400,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VISCOAT 0.5ML,4301402,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULCRAFATE SUSP 10ML,4301403,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUCRALFATE 1GM TABLET U/D,4301404,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEBIVOLOL 5MG TAB,4301405,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPIVACAINE 1% 30ML VL,4301408,CDM,636,RC,J0670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPIVACAINE 1.5% 30ML,4301410,CDM,636,RC,J0670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 9MG TAB,4301412,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPIVACAINE 2% 20ML VL,4301414,CDM,636,RC,J0670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPIVACAINE 2% 50ML,4301415,CDM,636,RC,J0670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM GLUCONATE 5ML,4301418,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIVIZUMAB  50MG POWD,4301420,CDM,636,RC,90378,HCPCS,Outpatient,,,0.01,0.01,,1202.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,339.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,611.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1188.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,781.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,339.68,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1202.46,
DILTIAZEM HCL 30MG TAB UD,4301422,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUDESONIDE 0.5MG 2ML UD,4301423,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM HCL 60MG TAB UD,4301424,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM HCL 90MG TAB UD,4301425,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE 2MG TAB,4301426,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM HCL 120MG TAB,4301427,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARISOPRODOL 350MG TAB UD,4301428,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIPERAC/TAZOBAC 4.5GM INJ,4301429,CDM,636,RC,J2543,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIPERAC/TAZOBAC A-V 4.5GM VIAL,4301431,CDM,636,RC,J2543,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 2MG/ML AKRON VIAL,4301432,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 500 MG IN 100 ML INJ,4301433,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1000 MG IN 200 ML INJ,4301434,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1250 MG IN 250 ML INJ,4301435,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1500 MG IN 300 ML INJ,4301437,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CASTOR OIL 60ML,4301439,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1750 MG IN 350 ML INJ,4301440,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 2000 MG IN 400 ML INJ,4301441,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOSPORINE 100MG CAP,4301445,CDM,636,RC,J7502,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE 0.3MG TAB U/D,4301446,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE 0.1MG TAB U/D,4301448,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPRATROPIUM BROM .03% SPY,4301449,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE 0.2MG TAB U/D,4301450,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE HCL .1MG PATCH,4301452,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE HCL .2MG PATCH,4301454,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE HCL .3MG PATCH,4301455,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GABAPENTIN 600MG TAB UD,4301456,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOTREXATE 1GM/40ML INJ,4301459,CDM,636,RC,J9250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRASTUZUMAB 10MG INJ 150MG VIAL,4301460,CDM,636,RC,J9355,HCPCS,Outpatient,,,0.01,0.01,,285.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,145.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,185.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,285.99,
TRASTUZUMAB-ANNS 10MG INJ (420MG),4301464,CDM,636,RC,Q5117,HCPCS,Outpatient,,,0.01,0.01,,86.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,86.16,
FLUCONAZOLE 40MG/ML 35ML,4301473,CDM,636,RC,J1450,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TAMSULOSIN  0.4MG CAP,4301475,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROAMPHETAMINE 5MG TAB,4301476,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFACLOR 250MG CAPSULE,4301478,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARTEOLOL 1% DROP 5ML,4301479,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CABERGOLINE 0.5MG TAB,4301483,CDM,636,RC,J8515,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM ACETATE 667 MG,4301487,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGFILGRASTIM-CBQV 0.5MG INJ (6MG SYR)FD,4301488,CDM,636,RC,Q5111,HCPCS,Outpatient,,,0.01,0.01,,533.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,150.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,271.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,527.73,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,346.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,533.76,
CALCIUM CARBONATE 500MG,4301489,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOMUSTINE 100MG CAPSULE,4301492,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARVEDILOL CR 10MG CAPSULE,4301496,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARVEDILOL 3.125MG TAB UD,4301497,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARVEDILOL 12.5MG TAB UD,4301499,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARVEDILOL 6.25MG TAB UD,4301500,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARVEDILOL 25MG TAB UD,4301501,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVASTIGMINE 3MG CAPSULE,4301502,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVASTIGMINE 1.5MG CAP,4301504,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MONTELUKAST 10MG TAB,4301506,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOFENAC/MISOPROSTOL 75,4301508,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEGASEROD 6MG TAB,4301510,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEVIRAPINE 200MG TABLET,4301512,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFUROXIME AXET 250MG TAB,4301513,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFUROXIME AXET 500MG TAB,4301515,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMOZOLOMIDE 20MG TAB,4301519,CDM,636,RC,J8700,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Injection to treat reaction to a drug,4301523,CDM,636,RC,J0702,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETH 10MG/ML 1ML,4301524,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMOZOLOMIDE 100MG CAP,4301526,CDM,636,RC,J8700,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAMETHASONE AUGMENT 0.05% 60ML LOT,4301527,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BIVALIRUDIN 250MG,4301528,CDM,636,RC,J0583,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SITAGLIPTIN-METFORMIN 50-500MG TABLET,4301532,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYTOCIN 30 UNITS/500 ML NS,4301533,CDM,636,RC,J2590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHOLRIDE 2.5 MEQ/1 ML ORAL SOLN,4301534,CDM,636,RC,J7131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRIMAQUINE 15MG (26.3MG) TABLET,4301535,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROMETHORPHAN 5MG/5ML,4301537,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIMODIPINE 60MG SOLN,4301539,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE 1.5MG TAB,4301544,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE 3MG TAB,4301545,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCITONIN 200U 3.7ML NAS,4301546,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESCITALOPRAM 5 MG TABLET,4301547,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMNIPAQUE 240 20ML INJ,4301549,CDM,636,RC,Q9966,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMNIPAGUE 180 10 ML INJ,4301551,CDM,636,RC,Q9965,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESVENLAFAXINE 50MG TAB,4301556,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOSARTAN 25 MG TABLET,4301558,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPOFOL 10M /ML 20ML,4301559,CDM,636,RC,J2704,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERAMIVIR 200MG/20ML VIAL,4301560,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTULOSE 300ML ENEMA,4301563,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTULOSE 20GM/30ML UD,4301566,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 7MG TAB,4301568,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTAZOLAM 1MG TAB,4301577,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE MONO 30MG TAB,4301580,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESMOPRESSIN 0.1MG TAB,4301585,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TACROLIMUS 1MG CAPSULE,4301587,CDM,636,RC,J7507,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"Measles, mumps and rubella vaccine",4301589,CDM,636,RC,90707,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADALIMUMAB 20MG INJ,4301593,CDM,636,RC,J0135,HCPCS,Outpatient,,,0.01,0.01,,6494.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1834.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3302.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6420.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,4219.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,6494.09,
TETRACAINE 0.5% LOLLIPOP,4301595,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZALEPLON 5MG CAPSULE,4301599,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLOVENT 220MCG INHALER,4301600,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFPROZIL 500 MG TABLET,4301603,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMALIZUMAB 5MG INJ (150MG VIAL),4301604,CDM,636,RC,J2357,HCPCS,Outpatient,,,0.01,0.01,,138.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,89.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.37,
AMLODIPINE/BENAZEP 2.5/10,4301605,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMALIZUMAB 5MG INJ (150MG VIAL) FD,4301606,CDM,636,RC,J2357,HCPCS,Outpatient,,,0.01,0.01,,138.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,89.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.37,
OMALIZUMAB 5MG INJ (150MG VIAL) FD,4301610,CDM,636,RC,J2357,HCPCS,Outpatient,,,0.01,0.01,,138.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,89.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.37,
VITAMIN D 400UI TAB,4301613,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VORICONAZOLE 40MG/ML SUSP (60ML),4301614,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORP MAL 2MG/5ML 5ML UD,4301615,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLOR-PHENIRAMINE 4MG,4301616,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMALIZUMAB 5 MG INJ (150 MG SYR) FD,4301617,CDM,636,RC,J2357,HCPCS,Outpatient,,,0.01,0.01,,138.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,89.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.37,
CHLORPHEN MAL 12MG TAB SA,4301618,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORAL HYDRATE 500MG/5ML,4301623,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPRAT/ALBUT 14.7GM INH,4301625,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENASEPTIC 180ML,4301626,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETHACRYNATE SOD 50MG VIAL,4301635,CDM,250,RC,,,Outpatient,,,463.6,278.16,,83.45,18,,,percent of total billed charges,pays at 18% of total charges,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,231.8,50,,,percent of total billed charges,pays at 50% of total billed charges,324.52,70,,,percent of total billed charges,70% of total billed charges,347.7,75,,,percent of total billed charges,75% of total billed charges,231.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,370.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,278.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,354.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,324.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,278.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,463.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,417.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.65,463.6,
VORICONAZOLE 100MCG/0.1ML OPTHALMIC SOLN,4301639,CDM,636,RC,J3465,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTAZIDIME 2.25MG/0.1ML OPTHALMIC SOLN,4301640,CDM,636,RC,J0713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPATITIS B 10MCG VACCINE (PEDI),4301649,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
HEPATITIS B 5MCG VACCINE  PEDI,4301650,CDM,636,RC,90744,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN REGULAR 100 UNITS/100ML IV DRIP,4301654,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN REGULAR HUMAN 1UN,4301655,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROMAZINE 10MG TAB,4301656,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ITRACONAZOLE 100MG CAP,4301659,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROMAZINE 25MG TABUD,4301660,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LABETALOL 5MG ML 40ML,4301661,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROMAZIN 200MG TABUD,4301670,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DINOPROSTONE CERVICAL GEL,4301671,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROMAZINE 50MG INJ (25MG/1ML),4301674,CDM,636,RC,J3230,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROMAZINE 50MG (50MG/2ML),4301676,CDM,636,RC,J3230,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALUMINUM CHLORIDE 20% 3ML SOLN,4301679,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% W/EPINEPHRINE 1 ML INJ,4301681,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% W/ EPINEPHRINE 1 ML INJ,4301682,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% 1 ML INJ,4301683,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RALOXIFENEHCL 60MG  TAB,4301684,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COLLAGENASE 1 GM OINT,4301686,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESOXIMETASONE 0.05% CREAM 60GM,4301691,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CRASH CART LOCK,4301693,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
OLANZAPINE 10MG TAB,4301696,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MUPIROCIN 2% 1 GM OINT,4301700,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL BACTERIOSTATIC 1ML INJ,4301701,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE ACETATE 7.5MG (ELIGARD),4301703,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
LEUPROLIDE ACET 30MG KIT (ELIGARD),4301704,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
SEVELAMER CARB 0.8 GRAM PACKET,4301705,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE (LUPRON 30MG) PER 7.5MG,4301706,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
LEUPROLIDE (LURPON 45MG) PER 7.5,4301707,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
CLOPIDOGREL 75MG TABS UD,4301713,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COVID-19 VAC 30MCG/0.3ML(PFIZER),4301714,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COVID-19 VAC 100MCG/0.5ML(MODERNA),4301715,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL PATIENT SPEC MED,4301717,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
COVID-19 VAC 30MCG/0.3ML(PFIZER),4301718,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (PFIZER) 1,4301718,CDM,771,RC,0001A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
COVID-19 VAC 30MCG/0.3ML(PFIZER),4301719,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (PFIZER) 2,4301719,CDM,771,RC,0002A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
COVID-19 VAC 30MCG/0.3ML(PFIZER),4301721,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE 3 (PFIZER),4301721,CDM,771,RC,0003A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
ADMIN PNEUMONIA VACCINE,4301722,CDM,771,RC,G0009,HCPCS,Outpatient,,,45.5,27.3,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.85,70,,,percent of total billed charges,70% of total billed charges,34.13,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,34.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.43,100,,,Case rate,pays based on per visit rate,40.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,136.34,
"PNEUMOCOCCAL CONJ VAC, 13 VALENT",4301722,CDM,636,RC,90670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN PNEUMONIA VACCINE,4301723,CDM,771,RC,G0009,HCPCS,Outpatient,,,45.5,27.3,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.85,70,,,percent of total billed charges,70% of total billed charges,34.13,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,34.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.43,100,,,Case rate,pays based on per visit rate,40.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,136.34,
PNEUMOCOCCAL CONJ VAC-20 VALENT,4301723,CDM,636,RC,90677,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHOLEST/AQUAPHOR 120 GM OINT,4301734,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 10 UNITS/ML FLUSH 5ML,4301735,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 2MG/1ML LIQUID,4301745,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINIDINE SULFATE 300MG,4301748,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 250MG,4301753,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM CITRATE 300ML,4301754,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 500MG U/D,4301755,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 750MG,4301757,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAMIPEXOLE 0.125MG TAB,4301759,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOFENAC/MISOPROSTOL 50,4301760,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE 12.5MG TAB,4301761,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEZEPELUMAB-EKKO 210 MG INJ,4301762,CDM,636,RC,J2356,HCPCS,Outpatient,,,0.01,0.01,,65.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,18.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,33.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,42.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,65.77,
CEFOTAXIME 1GM VIAL INJ,4301770,CDM,636,RC,J0698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOTAXIME 2GM VIAL INJ,4301772,CDM,636,RC,J0698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN 150MG CAP UD,4301780,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 1MG INJ (50MG/10ML),4301782,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REMDESIVIR 100 MG INJ,4301783,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISDEXAMFETAMINE 30MG CAP,4301785,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MESALAMINE 250MG CAPSULE,4301786,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOLAZONE 10MG TABLET,4301791,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BIAFINE RE 1.65 OZ,4301793,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYUREA 100MG TABLET,4301794,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXALIPLATIN 100MG VIAL,4301801,CDM,636,RC,J9263,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB 10MG (400MG) INJ,4301803,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
GENTEAL GEL 3.5ML SEV RLF,4301804,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITAZOXANIDE 500MG TAB,4301805,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULINDAC 150MG TABLET UD,4301806,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE 22.5MG KIT (ELIGARD),4301807,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
LEUPROLIDE 45MG KIT (ELIGARD),4301808,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
BEVACIZUMAB 10MG INJ (400MG) FD,4301809,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
NITAZOXANIDE 100MG/5ML (60ML) SUSP,4301810,CDM,637,RC,J3430,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.9% 10ML INJ (50ML),4301811,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICOTINE 21MG PATCH (28 PATCHES),4301812,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONAZEPAM 0.5MG TAB,4301816,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONAZEPAM 1MG TAB,4301818,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONAZEPAM 2MG TAB,4301820,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORATADINE 5MG/5ML,4301822,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCYSTEINE 20% SOLN 4 ML,4301823,CDM,636,RC,J7608,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZINC OXIDE 12.8% OINT 2 OZ,4301824,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLTERODINE 2MG TAB,4301828,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SARGRAMOSTIM 500MCG/ML,4301829,CDM,636,RC,J2820,HCPCS,Outpatient,,,0.01,0.01,,206.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,58.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,104.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,203.91,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,133.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,58.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,206.24,
COCAINE HCL 4% 4ML UD,4301830,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN PEDI SYRINGE 4MG/ML,4301831,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOPOTECAN 4MG VIAL,4301834,CDM,636,RC,J9351,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTECAN 100MG INJ,4301836,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTECAN LIPOSOME 1MG (43MG/10ML) INJ,4301837,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 2MEQ INJ 30 ML,4301838,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERRIC DERISOMALTOSE 10MG INJ 10 ML,4301839,CDM,636,RC,J1437,HCPCS,Outpatient,,,0.01,0.01,,71.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,36.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,71.01,
CRIZANLIZUMAB-TMCA 5 MG INJ (100MG) C,4301843,CDM,636,RC,C9053,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISATUXIMAB-IRFC 10 MG INJ (100 MG),4301844,CDM,636,RC,J9227,HCPCS,Outpatient,,,0.01,0.01,,240.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,122.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,156.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,240.2,
ISATUXIMAB-IRFC 10 MG INJ (500 MG),4301845,CDM,636,RC,J9227,HCPCS,Outpatient,,,0.01,0.01,,240.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,122.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,156.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,240.2,
ETESEVIMAB 700 MG INJ FD,4301847,CDM,636,RC,Q0245,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BAMLANIVIMAB 700 MG INJ FD,4301848,CDM,636,RC,Q0245,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THYROTROPIN ALFA 1.1MG VL,4301849,CDM,636,RC,J3240,HCPCS,Outpatient,,,0.01,0.01,,7119.89,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2011.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3620.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7039.44,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4625.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2011.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,7119.89,
CODEINE SULF 30MG TAB UD,4301850,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMOTIDINE 0.2 MG/ML INJ PEDI,4301851,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOTROVIMAB 500 MG INJ (8 ML) FD,4301852,CDM,636,RC,Q0247,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENFORTUMAB VED-EJFV  0.25 MG INJ (20 MG),4301853,CDM,636,RC,J9177,HCPCS,Outpatient,,,0.01,0.01,,124.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,63.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,124.11,
BENZTROPINE 1MG/ML 2MLINJ,4301854,CDM,636,RC,J0515,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPIRUBICIN 2MG/ML 100ML,4301855,CDM,636,RC,J9178,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZTRO MESYL .5MG TAB UD,4301856,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPRED SODSUC 1MG/1ML,4301857,CDM,636,RC,J2920,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENFORTUMAB VED-EJFV 0.25 MG INJ (30 MG),4301858,CDM,636,RC,J9177,HCPCS,Outpatient,,,0.01,0.01,,124.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,63.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,124.11,
DARBEPOETIN ALFA 1MCG (25MCG) INJ,4301859,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
VANCOMYCIN 750MG IN 150 ML INJ,4301860,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 1MG/ML AMP  2ML,4301861,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZTROP MESYL 1MG TAB UD,4301862,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVASTIG 9.5MG/24HR PATCH,4301863,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENTROPI MESYL 2MG TAB UD,4301864,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1MG/0.1ML OPTHALMIC SOLN,4301865,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MITOMYCIN 0.04MG/ML OPTHALMIC SOLN,4301867,CDM,636,RC,J9280,HCPCS,Outpatient,,,0.01,0.01,,338.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,219.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.45,
OMACETAXINE MEP 3.5MG INJECTION,4301869,CDM,636,RC,J9262,HCPCS,Outpatient,,,0.01,0.01,,14.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,7.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.86,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,9.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3.96,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,14.01,
TOBRAMYCIN 14MG/ML OPTHALMIC SOLN,4301870,CDM,636,RC,J3260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 25MG/ML OPTHALMIC SOLN,4301871,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GANCYCLOVIR 5MG/0.1ML OPTHALMIC SOLN,4301872,CDM,636,RC,J1570,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALTEPLASE 125MCG/ML OPTHALMIC SOLN,4301873,CDM,636,RC,J2997,HCPCS,Outpatient,,,0.01,0.01,,315.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,315.62,
COLCHICINE .6MG TABLET,4301874,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFACETAMIDE 10% OPTH SOLN 5ML,4301875,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETHYL ALCOHOL 99% 5 ML INJ,4301877,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGFILGRASTIM-JMDB BIOSIM 0.5MG,4301878,CDM,636,RC,Q5108,HCPCS,Outpatient,,,0.01,0.01,,341.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,96.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,173.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,337.61,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,221.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,96.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,341.46,
IMMUNE GLOBULIN 10% 500MG 200ML FD,4301879,CDM,636,RC,J1561,HCPCS,Outpatient,,,,,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,174.38,
PEGILGRASTIM-APGF BIOSIM 0.5 MG,4301880,CDM,636,RC,Q5122,HCPCS,Outpatient,,,0.01,0.01,,314.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,88.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,311.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,204.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,88.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,314.98,
ROMIDEPSIN 0.1 MG INJ 10 MG KIT,4301881,CDM,636,RC,J9319,HCPCS,Outpatient,,,0.01,0.01,,108.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,55.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.31,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,70.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,108.53,
CABOTEG-RILPIV 2-3MG INJ 600-900 MG FD,4301882,CDM,636,RC,J0741,HCPCS,Outpatient,,,0.01,0.01,,78.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,22.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,40.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,51.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,78.9,
EFGARTIGIMOD ALFA-FCAB 2 MG INJ 20 ML,4301883,CDM,636,RC,J9332,HCPCS,Outpatient,,,0.01,0.01,,113.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,57.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.38,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,73.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,113.66,
CARIPRAZINE 6MG CAPSULE,4301889,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STALEVO 150MG TAB,4301896,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STALEVO 200 (50/200/200) TABLET,4301897,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GEMCITABINE 1GM INJ,4301898,CDM,636,RC,J9201,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GEMCITABINE 200MG INJ,4301900,CDM,636,RC,J9201,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN LIPOSOM 20MG,4301908,CDM,636,RC,Q2050,HCPCS,Outpatient,,,0.01,0.01,,512.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,260.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,333.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,512.76,
RIFAMPIN 600MG  25ML,4301916,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GANCYCLOVIR 2MG/0.1ML OPTHALMIC SOLN,4301917,CDM,636,RC,J1570,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GANCYCLOVIR 4MG/0.1ML OPTHALMIC SOLN,4301919,CDM,636,RC,J1570,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCHLORPERAZINE 25MG SUP,4301920,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 50MG/ML OPTHALMIC SOLN,4301921,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 50MG/1ML OPTHALMIC SOLN,4301922,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 100MG/0.5ML OPTHALMIC SOLN,4301923,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB 2.5MG/0.1ML OPTHALMIC SOLN,4301924,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
FLUOROURACIL 5MG/1ML OPTHALMIC SOLN,4301926,CDM,636,RC,J9190,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VORICONAZOLE 10MG/1ML OPTHALMIC SOLN,4301927,CDM,636,RC,J3465,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOXIFLOXACIN 0.5% 3ML,4301928,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MUPIROCIN 2% CREAM,4301929,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCHLORPERAZINE 5MG U/D,4301930,CDM,636,RC,Q0164,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINERAL OIL STERILE 2 ML,4301931,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCHLORPERAZINE 10MG U/D,4301932,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANIDULAFUNGIN 0.77 MG/ML PEDI,4301933,CDM,636,RC,J0348,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INFLIXMAB-AXXQ BIOSIM 10 MG (100MG) INJ,4301935,CDM,636,RC,Q5121,HCPCS,Outpatient,,,0.01,0.01,,93.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,47.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.64,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,60.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,93.7,
LANTHANUM CARB 500MG CHEW,4301942,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LURASIDONE 40MG (0.5 TAB UD),4301943,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BARICITINIB 2 MG TAB,4301947,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DULOXETINE 20MG CAP,4301951,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DULOXETINE 30MG CAP,4301952,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BARICITINIB 1 MG TAB,4301953,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DULOXETINE 60MG,4301954,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIKACIN 100MG,4301955,CDM,636,RC,J0278,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIKACIN 500MG/2ML INHALATION,4301956,CDM,636,RC,J0278,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RITUXIMAB-PVVR 10 MG INJ 10 ML,4301957,CDM,636,RC,Q5119,HCPCS,Outpatient,,,0.01,0.01,,78.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,40.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.05,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,51.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,78.94,
RITUIMAB-PVVR 10 MG INJ 50 ML,4301958,CDM,636,RC,Q5119,HCPCS,Outpatient,,,0.01,0.01,,78.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,40.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.05,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,51.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,78.94,
BELANTAMAB MAF-BLMF 0.5 MG INJ 100 MG,4301959,CDM,636,RC,J9037,HCPCS,Outpatient,,,0.01,0.01,,165.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.72,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,107.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,165.6,
ALPRAZOLAM XR 0.5MG TAB,4301960,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALPRAZOLAM XR 1MG,4301961,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAFCILLIN 25 MG/ML INJ PEDI,4301962,CDM,636,RC,J3490,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLUCOSE 4 GM TAB,4301963,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRIL SUSP 1MG/ML 40ML,4301965,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIPTORELIN 3.75MG (22.5MG SYRINGE),4301966,CDM,636,RC,J3315,HCPCS,Outpatient,,,0.01,0.01,,1422.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,401.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,723.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1406.12,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,924.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1422.19,
MEDROXYPROGESTERONE 150MG,4301974,CDM,636,RC,J1050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIVANTAMAB-VMJW 2 MG  INJ 350 MG,4301975,CDM,636,RC,J9061,HCPCS,Outpatient,,,0.01,0.01,,70.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,19.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,35.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.95,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,70.76,
CETUXIMAB 10MG (100MG) INJ,4301976,CDM,636,RC,J9055,HCPCS,Outpatient,,,0.01,0.01,,255.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,130.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.98,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,166.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,255.87,
AMIODARONE 200MG TABLET,4301977,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOUTHKOTE 2OZ REG AF,4301979,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOSAMPRENAVIR CA 700MG TB,4301980,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CINACALCET HCL 30MG TAB,4301981,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIV W/ EPI 0.25% CSP (30ML) INJ,4301982,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 10MG/ML 10ML VIAL,4301985,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METRONIDAZOLE VAG GEL 70G,4301986,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIV W/ EPI 0.25% CSP (50ML) INJ,4301987,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIV W/ EPI 0.5% CSP (30ML) INJ,4301990,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTAROLINE 400MG VIAL,4301999,CDM,636,RC,J0712,HCPCS,Outpatient,,,0.01,0.01,,13.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,6.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.51,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,3.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,13.66,
UREA 40% CREAM 199GM,4302001,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN SUSP 32MG/ML,4302002,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GABAPENTIN 400MG CAP UD,4302003,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN 75MG/5ML,4302004,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 10MG/10ML SOLN,4302005,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 250MG/5ML,4302006,CDM,636,RC,J0744,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VORICONAZOLE 200MG TAB,4302008,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAFFEINE CITRATE ORAL 20MG/ML,4302010,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VORICONAZOLE 10.00 MG/ML,4302011,CDM,636,RC,J3465,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCITRIOL LIQD 0.5MCG/0.5ML,4302012,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE ELIX 0.1MG/ML,4302013,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRABECTEDIN 0.1MG INJ (1MG),4302014,CDM,636,RC,J9352,HCPCS,Outpatient,,,0.01,0.01,,1197.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,338.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,609.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1184.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,778.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,338.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1197.97,
DIGOXIN SOLN 50MCG/ML - ML,4302015,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THALIDOMIDE 100MG CAPSULE,4302017,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARFILZOMIB 1MG (60MG) INJ,4302019,CDM,636,RC,J9047,HCPCS,Outpatient,,,0.01,0.01,,166.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,107.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,166.02,
CARFILZOMIB 1MG (30MG) INJ,4302021,CDM,636,RC,J9047,HCPCS,Outpatient,,,0.01,0.01,,166.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,107.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,166.02,
CARFILZOMIB 1MG (10MG) INJ,4302022,CDM,636,RC,J9047,HCPCS,Outpatient,,,0.01,0.01,,166.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,107.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,166.02,
ERGOCALCIFEROL (VITAMIN D2) DROP 4000U,4302023,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN ETHYLSUCCINATE SUSR 40M,4302024,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE HCL 100MCG/ ML 10ML VIAL,4302026,CDM,636,RC,J0735,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS SULFATE DROP 15MG/ML - 1ML,4302027,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE ORAL SOLN 10MG/ML - 1ML,4302028,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYOSCYAMINE SULFATE DROP 0.125MG/ML,4302029,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTOBACILLUS DROPS - 0.25ML,4302030,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSOPRAZOLE (PREVACID) SUSR 3MG/ML,4302031,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACETAM SOLN 100MG/ML,4302033,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NADOLOL 40MG TABLET UD,4302034,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHADONE SOLN 0.5MG/0.5ML,4302035,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NADOLOL 80MG TABLET UD,4302036,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOCLOPRAMIDE SOLN 1MG/1ML,4302037,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM SYRP 1MG/0.5ML,4302038,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE SOLN 1MG/0.5ML,4302039,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEDIATRIC MULTIVITAMINS DROP - 1ML,4302040,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEDIATRIC MULTIVITAMINS - IRON DROP -1MG,4302041,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENOBARBITAL ELIX 4MG/ML,4302042,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE SODIUM PHOSPHATE SOLN 1,4302043,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE SOLN 3MG/ML,4302044,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANITIDINE HCL SYR 15MG/ML,4302045,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMETHICONE DRPS 20MG/0.3ML,4302046,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIDOVUDINE SYRP 10MG/ML,4302047,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SPIRONOLACTONE 1MG/ML ORAL SOLN 1ML,4302049,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERTUZ-TRASTUZ-HYAL 10MG INJ (1200MG),4302051,CDM,636,RC,J9316,HCPCS,Outpatient,,,0.01,0.01,,240.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,67.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,122.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.68,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,156.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,240.4,
HYDROCORTISONE 100MG/60ML,4302098,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOFLOXACIN 50MG/ML ORAL SOLN 1ML,4302099,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENAZEPRIL 20MG TAB,4302102,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENAZEPRIL 40MG TAB,4302103,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SAXAGLIPTIN 2.5MG TABLET,4302104,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 23.4% (4MEQ/ML) 200ML,4302106,CDM,250,RC,J7131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACLOFEN 10MG/ML ORAL SOLN 1ML,4302107,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CORTISONE ACETAT 25MG TAB,4302108,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE IN DEX 10MG (PF) 0.8% 250ML,4302109,CDM,636,RC,J2001,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CORTISPORIN CREAM   7.5GM,4302110,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE 1MG/ML ORAL SOLN 1ML,4302111,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CORTISPORIN OINT 15GM,4302112,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEO/BACI/POLY/HC 3.5GM OI,4302113,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CORTISPORIN OPH 7.5ML,4302114,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEOMYCIN/POLY/HC OTIC SOL,4302116,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALISKIREN 300MG TAB,4302117,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CORTISPORIN OTIC SUS 10ML,4302118,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALISKIREN 150MG TAB,4302119,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COSYNTROPIN .25MG  VIAL,4302126,CDM,636,RC,J0834,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN 200MG/5ML,4302128,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDRALAZINE 4MG/ML ORAL SOLN 1 ML,4302129,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARVEDILOL 0.1MG/ML ORAL SOLN 1ML,4302130,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONAZEPAM 0.1MG/ML ORAL SOLN 1ML,4302131,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLONIDINE 0.1MG/ML ORAL SOLN 1ML,4302132,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCHLOROTHIAZIDE 5MG/ML SOLN 1ML,4302133,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHYTONADIONE 1MG/ML ORAL SOLN 1ML,4302134,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISDEXAMFETAMINE 50MG CAP,4302135,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILDENAFIL 2.5MG/ML ORAL SOLN 1ML,4302136,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAPTOPRIL 1MG/ML ORAL SOLN 1ML,4302137,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 2MG/ML ORAL SOLN 1ML,4302138,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SPIRONOLACTONE 5MG/ML ORAL SOLN 1ML,4302139,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAMIVUDINE/ZIDOVUDINE,4302140,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 25MG/ML ORAL SOLN 1ML,4302141,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 2MG TABLET UD,4302142,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 12MG/ML ORAL SOLN 1ML,4302143,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETHANECHOL 5MG/ML ORAL SOLN 1ML,4302144,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMLODIPINE 1MG/ML ORAL SOLN 1ML,4302146,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOCARNITINE 1GM/5ML,4302147,CDM,636,RC,J1955,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 2.5MG TABLET UD,4302148,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METRONIDAZOLE 50MG/ML ORAL SOLN 1ML,4302149,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM ZIRCONIUM 5GM SUSP,4302150,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPREN/NALOX 8-2MG TAB,4302153,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 5MG TABLET UD,4302154,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATORVASTATIN 10MG TABLET,4302155,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 7.5MG TABLET UD,4302158,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 5.5MG TABLET,4302159,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUETIAPINE 100MG TABLET,4302162,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CETIRIZINE 1MG/ML SYRUP,4302172,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEDIATRIC MULTIVITAMIN DROPS W/IRON 1 ML,4302173,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAROXETINE 30MG TABLET,4302176,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLNALTREXONE 8MG/0.4ML SYRINGE,4302179,CDM,636,RC,J2212,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLNALTREXONE 0.1MG INJ,4302180,CDM,636,RC,J2212,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOCARNITINE 100 MG/ML 1ML ORAL SOLN,4302183,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN 500MG,4302184,CDM,636,RC,J0456,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAROXETINE 10MG TABLET,4302185,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOCARNITINE 5ML ORAL SOLN,4302187,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOMETASONE 0.1% OINT 15GM,4302189,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYANIDE ANTIDOTE PACK 1EA,4302190,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOMETASONE 0.1% CR 15GM,4302191,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYANOCOBALAMIN 1000MCG/ML,4302192,CDM,636,RC,J3420,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRBESARARTAN  150MG TAB,4302193,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRADIOL 0.05 PACK,4302195,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN 2MG/ML PEDI,4302196,CDM,636,RC,J0456,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EMEDASTINE 0.05% 6ML OPHTH DROPS,4302199,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIFAMPIN 150MG CAPS,4302202,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE VALER 0.2% 15GM CREAM,4302203,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIROFIBAN 12.5MG/250ML PREMIX,4302205,CDM,636,RC,J3246,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RHO(D) IMM GLOB 5000 IU,4302206,CDM,636,RC,J2792,HCPCS,Outpatient,,,0.01,0.01,,118.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,60.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,118.44,
HYDROCORTISONE BUTYRATE 0.1% 15GR OINT,4302207,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COMPOUNDING VEHICLE NO 8 30ML,4302208,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RHO(D) IMM GLOB 2500 IU,4302210,CDM,636,RC,J2792,HCPCS,Outpatient,,,0.01,0.01,,118.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,60.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,118.44,
ARIPIPRAZOLE 15MG TABLET,4302218,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN GLARGINE 1 UNIT,4302220,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREGABALIN 25MG CAP,4302222,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FEBUXOSTAT 40MG TAB,4302223,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIODARONE 100MG TAB,4302224,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METFORMIN XR 750MG TAB,4302225,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPENTOLATE 1% DROPS 2,4302226,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPENTALATE 2% DROPS 2,4302232,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NESIRITIDE 0.5MG/1.67ML,4302233,CDM,636,RC,J2325,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENTACAPONE 200MG TAB,4302234,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPENTOLATE 1% DROPS 15,4302237,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAMISIL 1% CREAM,4302245,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 500MG INJ,4302253,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METFORMIN  850MG,4302255,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIRTAZAPINE 30MG SOLTAB,4302257,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 0.3% OP OIN,4302259,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYPROHEPTADINE 4MG TAB,4302260,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPHETAMINE MIXTURE ER 10,4302261,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYBUR/METFORMIN 1.25/250,4302262,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"THROMBIN 5,000U",4302263,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIGLITOL 25MG TAB,4302265,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TICAGRELOR 90MG TAB,4302266,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUCROSE 24% SOLUTION,4302270,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DENOSUMAB 120MG VIAL,4302274,CDM,636,RC,J0897,HCPCS,Outpatient,,,0.01,0.01,,85.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.77,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,55.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,85.73,
DENOSUMAB 60MG VIAL,4302275,CDM,636,RC,J0897,HCPCS,Outpatient,,,0.01,0.01,,85.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.77,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,55.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,85.73,
CYTARABINE 100MG VIAL INJ,4302276,CDM,636,RC,J9100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPHOSPHAMIDE 1GM INJ,4302282,CDM,636,RC,J9070,HCPCS,Outpatient,,,0.01,0.01,,63.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,32.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.79,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,63.5,
WARFARIN 15MG TABLET,4302287,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FORMOTEROL 12MCG 12EA,4302288,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis A vaccination for adults,4302291,CDM,636,RC,90632,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIMEXOLONE 1% 5ML OPHTH DROPS,4302293,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIHYDROERGOT 1.00 MG/ML,4302294,CDM,636,RC,J1110,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPHENIDAYE ER 18MG,4302296,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAKIN'S SOLN (MOD),4302301,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CELECOXIB 200MG CAP UD,4302308,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVALBUTEROL 0.63MG NEBULE,4302310,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COCAINE 4% 10ML TOP,4302311,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUANFACINE ER 2MG TAB,4302313,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINAPRIL 10MG TAB,4302314,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUANFACINE ER 1MG TAB,4302315,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARATUMUMAB 400 MG/20 ML VIAL,4302316,CDM,636,RC,J9145,HCPCS,Outpatient,,,0.01,0.01,,219.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,111.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.45,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,142.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,219.94,
DARATUMUMAB 100 MG/5 ML VIAL,4302317,CDM,636,RC,J9145,HCPCS,Outpatient,,,0.01,0.01,,219.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,111.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.45,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,142.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,219.94,
DANTROLENE 20MG VIAL INJ,4302322,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DANTROLENE 25MG CAP,4302324,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DORZOLAMIDE HCL-TIMOLOL MAL 2%/0.5% 3ML,4302325,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DANTROLENE 100MG CAP,4302326,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARAPRIM 25MG TABLET,4302333,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAPSONE 25MG TAB,4302335,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 1MG TAB,4302336,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMVASTATIN 40MG TABLET,4302337,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HUMAN PAPILLOMAVIRUS QUAD VAL VAC 0.5ML,4302338,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NATEGLINIDE 60MG TABLET,4302339,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETH SOD PHOS .1% 5ML,4302341,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 80MG/2ML VIAL-PF,4302345,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEOMYCIN/POLY/PRAMO 14.2 GM CREAM,4302355,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEROPENEM 100MG INJ (1GM),4302356,CDM,636,RC,J2185,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEROPENEM 100MG INJ (500MG),4302357,CDM,636,RC,J2185,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OFLOXACIN 0.3% OPHTH 5ML,4302358,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEROPENEM/VABORBACTAM 10/10MG INJ 2 GM,4302359,CDM,636,RC,J2186,HCPCS,Outpatient,,,0.01,0.01,,7.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.28,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,4.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2.08,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,7.36,
EPINEPHRINE 1MG INJ (1ML),4302365,CDM,636,RC,J0171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXI/POT CLAU 600 75ML,4302370,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RACEMICEPINE 2.25% 0.5ML,4302371,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESMOPRESSIN 4MCG/ 1ML,4302384,CDM,636,RC,J2597,HCPCS,Outpatient,,,0.01,0.01,,21.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.52,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,14.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,6.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.77,
PEMBROLIZUMAB 1MG INJ (50MG VIAL),4302385,CDM,636,RC,J9271,HCPCS,Outpatient,,,0.01,0.01,,199.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,101.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,129.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,199.69,
DESMOPRESSIN 0.1MG/ML SOL,4302386,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE DISKUS 100MCG/ACTUATION,4302387,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE DISKUS 250MCG/ACTUATION,4302388,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE DISKUS 50MCG/ACTUATION,4302389,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBAMIDE PEROXIDE 15ML,4302390,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE 100MCG/ACT DISKUS 60,4302391,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE 250MCG/ACT DISKUS 60,4302392,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIFLUPREDNATE OPTH DROP 0.05% 5ML,4302434,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEMECLOCYCLINE 150MG TAB,4302444,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMETREXED 10MG INJ,4302445,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
DEMECLOCYCLINE 300MG TAB,4302448,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOPINAVIR/RITON 200/50,4302455,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VENLAFAXINE XR 150MG CAP,4302458,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERTAPENEM 1GM ADV VIAL,4302459,CDM,636,RC,J1335,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DECONAMINE SR CAPSULE,4302460,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFEPIME 1 GRAM ADV VIAL,4302461,CDM,636,RC,J0692,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE 5MG TAB,4302462,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFEPIME 20MG/ML NSY,4302465,CDM,636,RC,J0692,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TREPROSTINIL SOD 1MG/ML 20ML VIAL,4302467,CDM,636,RC,J3285,HCPCS,Outpatient,,,0.01,0.01,,198.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,100.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.03,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,128.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,56.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,198.27,
HYDROXYPROGESTERONE 10MG INJ,4302468,CDM,636,RC,J1726,HCPCS,Outpatient,,,0.01,0.01,,48.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,24.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,48.92,
WARFARIN 14MG TABLET,4302471,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OPIUM TINCTURE 10MG/ML,4302472,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETHYL ALCOHOL INTRANASAL,4302475,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BRONCHOSCOPY KIT,4302476,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
LACOSAMIDE 50MG TABLET,4302477,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 7% 4ML INHALATION,4302483,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAPECITABINE 150MG TAB,4302486,CDM,636,RC,J8520,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRON SUCROSE 20MG/ML 5ML,4302488,CDM,636,RC,J1756,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE 15MG TAB,4302489,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MITOMYCIN 5MG (40MG/20ML) BLADDER IRRIG,4302491,CDM,636,RC,J9280,HCPCS,Outpatient,,,0.01,0.01,,338.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,219.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.45,
NISOLDIPINE 20MG TAB,4302495,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACITRACIN ZINC OINT 30GM,4302496,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CICLOPIROX 0.77% 30GM CRM,4302498,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALPROATE NA 250MG/5ML UD,4302500,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALPROIC ACID 250MG U/DUD,4302504,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIVALPROEX 500MG UD TAB,4302512,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRADIOL CYP. 5MG/ML 5ML,4302516,CDM,637,RC,J1000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPREDNISOLONE 40MG I,4302520,CDM,636,RC,J2920,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 30 UNIT/3 ML SYRINGE,4302521,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPREDNISOLONE 80MG I,4302524,CDM,636,RC,J1040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TESTOSTERONE CYP 100MG/ML,4302536,CDM,636,RC,J1071,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOCAINE-MENTHOL 20-0.5% 56 ML TOP,4302546,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SEVOFLURANE 250ML,4302549,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE SULF 250MG/10ML,4302551,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 50MG/ML 20ML SDV,4302552,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFPROZIL 250MG TABLET,4302554,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROAMPHETAMINE 10MG SR,4302555,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATOVAQUONE 750MG/5ML SUSP,4302557,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 2MG/ML SYRUP 5ML,4302559,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATOVAQUONE/PROGUANIL 250-100MG TABLET,4302561,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOPIRAMATE 200MG TAB,4302562,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GOSERELIN 3.6MG IMP,4302563,CDM,636,RC,J9202,HCPCS,Outpatient,,,0.01,0.01,,2164.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,611.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1100.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2139.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1406.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,2164.17,
HYDROCODONE-APAP 2.5MG-108MG 5ML,4302564,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZONISAMIDE 100MG CAP,4302565,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZEASORB-AF 2% 70GM,4302567,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOMETASONE 0.1% 45GM,4302569,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUDESONIDE EC 3MG CAP,4302572,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZOLEDRONIC ACID 4MG/5ML,4302573,CDM,636,RC,J3489,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 40MG/ML 20ML VIAL,4302575,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRAZODONE 50MG TAB UDD,4302580,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 10MG INJ (50MG/ML 50ML),4302581,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRAZADONE 100MG TAB UDD,4302582,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GOSERELIN 3.6 MG IMP 10.8 MG SYR,4302583,CDM,636,RC,J9202,HCPCS,Outpatient,,,0.01,0.01,,2164.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,611.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1100.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2139.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1406.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,611.35,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,2164.17,
TRAZADONE 150 TABLET,4302584,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERGOCALCIFEROL 8000U 60ML,4302585,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN / LIDOCAINE (1:1),4302586,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSOPRAZOLE 15MG CAP,4302591,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHROID 0.088MG TAB,4302592,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFEPIME 1000MG VIAL,4302596,CDM,636,RC,J0692,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLIMEPIRIDE 2MG TAB UD,4302598,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACARBOSE 50MG TABLET,4302599,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICOTINE INHALER KIT 10MG,4302601,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE .5MG/5ML UD,4302602,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE MONO 120MG TAB,4302604,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RITUXIMAB PER 10MG INJ (500MG VIAL),4302605,CDM,636,RC,J9312,HCPCS,Outpatient,,,0.01,0.01,,283.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,144.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,184.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,283.87,
GALANTAMINE 4MG TAB,4302607,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE 1MG TAB,4302608,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALPHA-1 PROTEINASE INHIBITOR HUMAN 10MG,4302609,CDM,636,RC,J0256,HCPCS,Outpatient,,,0.01,0.01,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.82,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,17.02,
DOCETAXEL 20MG INJ.,4302610,CDM,636,RC,J9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CELECOXIB 100MG CAP UD,4302612,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCETAXEL 1MG INJ,4302614,CDM,636,RC,J9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 500 MG,4302615,CDM,636,RC,J1561,HCPCS,Outpatient,,,0.01,0.01,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,174.38,
DEXAMETHASONE 4MG/ML 5ML,4302616,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE 4MG/ML 1ML,4302618,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZANAMIVIR INHALATION POWDER 5MG,4302621,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVALBUTEROL 1.25MG/3ML NEBULE,4302623,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE 1.5MG TABUD,4302624,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RITUXIMAB 10MG INJ (100MG VIAL),4302625,CDM,636,RC,J9312,HCPCS,Outpatient,,,0.01,0.01,,283.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,144.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,184.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,283.87,
DEXAMETHASONE 4MG TAB UD,4302628,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEO/POLY/DEX 3.5GM OPH OINT,4302630,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAXITROL OPH DROPS 5ML,4302632,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CANDIDA ALBICANS TEST,4302635,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NALOXONE 1MG/ML SYRINGE,4302637,CDM,636,RC,J2310,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPATITIS B IMMUNE GLOBULIN >312UNITS/ML,4302638,CDM,636,RC,J1573,HCPCS,Outpatient,,,0.01,0.01,,220.04,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,62.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,111.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,217.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,142.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,220.04,
DEXTROSE 50% 50ML SYRINGE,4302642,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 25% 10ML,4302643,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 50  50ML VIAL IV,4302644,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD FERRIC GLUC COM 62.5M,4302646,CDM,636,RC,J2916,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE 50% 50ML INJ CSP,4302647,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SACUBITRIL/VALSARTAN 97MG-103MG TAB,4302649,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIPRASIDONE 20MG CAP,4302650,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOTAXIME 500MG INJ,4302651,CDM,636,RC,J0698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TENOFOVIR 300MG TAB,4302652,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROPINIROLE 1MG TAB,4302653,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 500 MG,4302654,CDM,250,RC,J1566,HCPCS,Outpatient,,,131.5,78.9,,271.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.75,50,,,percent of total billed charges,pays at 50% of total billed charges,92.05,70,,,percent of total billed charges,70% of total billed charges,98.63,75,,,percent of total billed charges,75% of total billed charges,137.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,105.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267.99,350,,,Fee Schedule,350% of CMS OPPS Rate,78.09,103,,,Fee Schedule,103% of CMS OPPS Rate,100.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,59.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,66.98,100,,,Fee Schedule,100% of UHC Fee Schedule,92.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,176.11,100,,,Fee Schedule,100% of CMS OPPS Rate,63.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,118.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,76.56,100,,,Fee Schedule,100% of CMS OPPS Rate,20.61,271.05,
EPTIFIBATIDE 2MG/ML 10ML VIAL,4302655,CDM,636,RC,J1327,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPTIFIBATIDE 0.75MG/ML 100ML,4302656,CDM,636,RC,J1327,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CABAZITAXEL 1MG (60MG) INJ,4302657,CDM,636,RC,J9043,HCPCS,Outpatient,,,0.01,0.01,,741.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,209.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,376.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,732.69,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,481.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,741.06,
SOD PICOSULF MAG OX CITRIC ACID PACKET,4302658,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANIFROLUMAB-FNIA 1 MG (300MG/2ML) INJ,4302659,CDM,636,RC,J0491,HCPCS,Outpatient,,,0.01,0.01,,58.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,16.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,29.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.1,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,38.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,58.76,
AMOX K/CLAV 875MG TABLET,4302662,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CITRATE 200MG TAB,4302663,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE/SALME 100/50,4302664,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPH/CYCLOPENT 2ML,4302665,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIAMINE 100MG/ML 2ML,4302666,CDM,636,RC,J3411,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCYSTEINE 600MG 3ML,4302667,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ABACAVIR LAMIVUD ZIDOV TAB,4302670,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BIMATOPROST 0.03% 2.5ML,4302671,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACETAM 250MG TAB,4302672,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPH CYCLOPENT 5ML,4302673,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROPAMIDE 250MG U/D,4302680,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBIDOPA/LEVO 50/200 ER,4302681,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB 0.625 MG/0.025ML OPHTH,4302685,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
CHLOROTHIAZIDE 250MG/5ML,4302686,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PETROLATUM FOILPAC,4302687,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSINOH OINT 0.25OZ,4302691,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SERTRALINE 20MG/ML,4302692,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE HCL 5MG TAB,4302693,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAZOLAMIDE 500MG CAP,4302694,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEDROXYPROGESTERONE 5MG,4302695,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAZOLAMIDE 500MG INJ,4302696,CDM,636,RC,J1120,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAZOLAMID 250MG TAB UD,4302698,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANASTROZOLE 1MG TAB,4302701,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINAPRIL 20MG,4302702,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOCETIRIZINE 5MG TAB,4302703,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE 1MG INJ (400MG)FD,4302704,CDM,636,RC,J0401,HCPCS,Outpatient,,,0.01,0.01,,24.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.87,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,24.14,
RISPERIDONE 2MG TABLET,4302705,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 2.5MEQ/ML 20ML SOLN,4302708,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 2.5MEQ/ML 40ML SOLN,4302710,CDM,250,RC,J7131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METFORMIN 500MG/5ML SOLN,4302714,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DURVALUMAB 10MG INJ (500MG),4302718,CDM,636,RC,J9173,HCPCS,Outpatient,,,0.01,0.01,,282.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,143.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.08,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,183.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,282.27,
PANTOPRAZOLE 40MG TABLET,4302720,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 1000MG IVPB,4302721,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 2000MG IVPB,4302722,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VENLAFAXINE XR 37.5MG CAP,4302724,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOXITIN 20MG/ML 50ML PEDI SYRINGE,4302726,CDM,636,RC,J0694,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOXITIN 1 GM PB,4302727,CDM,636,RC,J0694,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PARICALCITOL 1MCG/0.2ML 1ML VIAL,4302728,CDM,636,RC,J2501,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOXITIN 2 GM PB,4302729,CDM,636,RC,J0694,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIPRASIDONE 60MG CAP,4302730,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOROLAC TROM 0.5% 10ML DROPS,4302732,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFUROXIME 1500MG IVPB,4302733,CDM,636,RC,J0697,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOTETAN 1 GM VIAL,4302735,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN 100MG/2ML VIAL,4302738,CDM,636,RC,J1165,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYCERIN 30 ML,4302739,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALENDRONATE 10 MG TABLET,4302740,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TROPICAMIDE 1% OPTH. DROP,4302742,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN 50MG CHEW TABUD,4302744,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 2.5% 15ML OPTH,4302746,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTRIAXONE 1000MG VIAL,4302747,CDM,636,RC,J0696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTRIAXONE 2000MG VIAL,4302749,CDM,636,RC,J0696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEFLUNOMIDE 10MG TAB,4302751,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN 250MG/5ML VIAL,4302752,CDM,636,RC,J1165,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PORACTANT 80MG ML 1 5ML,4302753,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOTAXIME 1 GM PB,4302755,CDM,636,RC,J0698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN 100MG CAP U/D,4302756,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLURAZEPAM 15MG CAPSULE,4302758,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SAQUINAVIR  200MG CAP,4302760,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALUMINUM CHLORIDE 20% 35ML,4302762,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALUMINUM CHLORIDE 20% 60ML,4302764,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIKACIN 500 MG INJ,4302765,CDM,636,RC,J0278,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 400MG/200ML D5W,4302774,CDM,636,RC,J0744,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STERILE TALC 4GM,4302776,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 400 MG PB,4302777,CDM,636,RC,J1450,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 1MG/ML AMP,4302782,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN 500 MG VIAL,4302783,CDM,636,RC,J1364,HCPCS,Outpatient,,,0.01,0.01,,296.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,83.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,150.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.74,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,192.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,83.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,296.08,
HYDROMORPHONE 2MG/ML AMP,4302784,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 4MG/ML AMP,4302786,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METRONIDAZOLE 500MG PB,4302787,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 0.5 MG/0.5 ML SYR,4302788,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUETIAPINE 25MG TABLET,4302790,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFAMETH/TRIMETH 10ML PB,4302791,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 5% PATCH EA,4302797,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 2MG TAB U/D,4302798,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FORMOTEROL 20MCG/2ML NEB SOLN,4302799,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRACE-4 ELEMENTS NEONATE 1 ML INJ,4302800,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINACLOTIDE 145 MCG CAPSULE,4302810,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPHENIRAMINE / PSE DROPS 30ML,4302811,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINACLOTIDE 290 MCG CAPSULE,4302812,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPRENORPHINE 10MCG/HOUR PATCH,4302813,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSOPRAZOLE 30MG TAB ODT,4302825,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"SYRUP, CHERRY 30ML EA",4302826,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEVIRAPINE 50MG/5ML,4302828,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUMETANIDE 2 5MG 10ML,4302842,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUMETANIDE 12.5MG/50ML drip,4302843,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BROM/PHENYLEPH/DEX DX 5ML,4302844,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BROM/PSEUDO/DEX DX 5ML,4302845,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROFLUMILAST 500MCG TAB,4302847,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINEZOLID 600MG TAB,4302852,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDINAVIR 400MG CAP,4302857,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSOPRAZOLE 30MG/10ML,4302858,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDRAMINE 50MG VIAL,4302860,CDM,636,RC,J1200,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"BUPIVACAINE-EPI 0.5%-1:200,000 10ML",4302863,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HISTAMINE SKIN TEST 1MG/ML (5ML) MDV,4302864,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TET & DIPTH 0.5ML PEDI,4302866,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAMETH DIPROP 0.05%CR15,4302874,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILDENAFIL 2.5MG/ML 120ML,4302875,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAMETH. DIPROP. CREAM 0.05% 45GM,4302876,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAME DIPRO .05% 15GM OINT,4302882,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SALSALATE 500MG TAB U/D,4302888,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SALSALATE 750MG TAB U/D,4302890,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FACTOR VIII RECOMBINANT PER UNIT,4302891,CDM,636,RC,J7192,HCPCS,Outpatient,,,0.01,0.01,,5.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.7,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.25,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5.31,
ALENDRONATE 70MG TAB,4302892,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOLIFENACIN SUCC 10MG TAB,4302896,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYBUTYNIN SYRUP 5ML UD,4302897,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYBUTYNIN 5MG TAB UDD,4302898,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAFENIDE ACETATE 60GM,4302899,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 20MG/5ML,4302916,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOSARTAN/HCTZ 50/12.5 TAB,4302917,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROSE-WATER/BUPIVACAIN,4302918,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPRO/HC OTIC 10ML,4302922,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOPROLOL XL 25MG TAB,4302927,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOBUTAMINE  250MG/20ML VL,4302928,CDM,636,RC,J1250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOBUTAMINE PEDI 12.5MG/ML 20ML VIAL,4302929,CDM,636,RC,J1250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCUSATE SOD 50MG CAP,4302932,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REMIFENTANIL 1MG VIAL,4302933,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCUSATE SOD 100MG CAP UD,4302934,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCUSATE SOD 100 MG/10 ML,4302935,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOBETASOL PROPIONATE 0.05% CREAM 15GM,4302936,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIPOTRIENE 0.005% CREAM 60GM,4302938,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIPOTRIENE 0.005% CREAM 120GM,4302939,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHACHOLINE 100MG,4302941,CDM,636,RC,J7674,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIRTAZAPINE SOLTAB 15MG,4302942,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALAMINE/ZN 4 INCH BANDAG,4302950,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LODOXAMIDE .1% 10ML,4302961,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CITALOPRAM 20MG TAB UD,4302963,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOPIRMATE 25MG TAB,4302964,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BELLADONNA/PB 5ML ELIXIR,4302970,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RISPERIDONE 1MG ML SOL.,4302971,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DONNATAL TABLET,4302972,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZYPREXA 5MG TABLET,4302973,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIFLORASONE 0.05% CREAM 60GM,4302974,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINOLONE 0.01% 60ML,4302975,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOSPHENYTOIN 100MG/2ML,4302977,CDM,636,RC,Q2009,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOSPHENYTOIN 50MG/ML 10ML,4302981,CDM,636,RC,Q2009,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE .1% CR 454G,4302986,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOPAMINE 40 MG/ML 5ML VIAL,4302994,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREVACID IV 30MG VIAL,4302995,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOPAMINE 400MG/5ML VIAL,4302996,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 10% 100ML,4302997,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
DOPAMINE 800MG/5ML VIAL,4302998,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOPAMINE 400MG/10ML VIAL,4302999,CDM,636,RC,J1265,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXAPRAM 20MG/ML 20ML INJ,4303000,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE/PRILOCAINE 5GM,4303001,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUTILIDE 1.00MG 10ML VL,4303002,CDM,636,RC,J1742,HCPCS,Outpatient,,,0.01,0.01,,793.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,224.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,403.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,784.1,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,515.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,224.03,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,793.06,
LIDOCAINE 1% MPF 2ML VIAL,4303003,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN BIOSIMILAR 1000 UNITS(40,000IU",4303004,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
"EPOETIN BIOSIMILAR 1000UNITS(10,000IU VI",4303005,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
LIDOCAINE 1 % 10ML INJ FD,4303007,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPOFOL 100ML,4303012,CDM,636,RC,J2704,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SELENIUM 40MCG/ML 10ML VIAL,4303014,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITRATEST PAPER,4303016,CDM,257,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXYCYCLINE 100MG VIAL IV,4303022,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXYCYCLINE 50MG CAP UD,4303023,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAMIPEXOLE 1MG TAB,4303024,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBAMAZEPINE XR 100MG TA,4303025,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANTI-INHIBITOR 651-1200 UNITS,4303031,CDM,636,RC,J7198,HCPCS,Outpatient,,,0.01,0.01,,8.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.14,
OLMESARTAN 20MG TAB,4303034,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATORVASTATIN 40MG TAB,4303035,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATORVASTATIN 80MG TAB,4303036,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN FOR NEB 300MG,4303037,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MONSELS FERRIC SUBSULFATE,4303038,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MILNACIPRAN 100MG TABLET,4303039,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HUMAN PROTHROMBIN COMPLEX 500 UNITS,4303040,CDM,636,RC,J7168,HCPCS,Outpatient,,,0.01,0.01,,8.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,5.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.07,
HUMAN PROTHROMBIN COMPLEX 1000 UNITS,4303041,CDM,636,RC,C9132,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FACTOR IX COMPLEX 500 (+/-),4303043,CDM,636,RC,J7194,HCPCS,Outpatient,,,0.01,0.01,,5.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5.69,
FACTOR IX COMPLEX 1000 (+/-),4303044,CDM,636,RC,J7194,HCPCS,Outpatient,,,0.01,0.01,,5.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5.69,
ANTI-INHIBITOR 400 - 650 UNITS,4303045,CDM,636,RC,J7198,HCPCS,Outpatient,,,0.01,0.01,,8.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.14,
DEXAMETHASONE 10MG/ML 10ML VIAL,4303047,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DACARBAZINE 200MG INJ,4303048,CDM,636,RC,J9130,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANTI-INHIBITOR 1750 - 3250 UNITS,4303049,CDM,636,RC,J7198,HCPCS,Outpatient,,,0.01,0.01,,8.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.14,
MIDAZOLAM 1MG/ML 5ML VIAL,4303051,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBOPOETIN 1 MCG (40MCG) INJ ESRD,4303052,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
DARBOPOETIN 1 MCG (40MCG) INJ,4303053,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
MORPH SULF 0.5MG/ML10ML AMP,4303076,CDM,636,RC,J2274,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPH SULF 1MG/ML 10ML AM,4303078,CDM,636,RC,J2274,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VECURONIUM 20MG INJ,4303079,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEMIPLIMAB-RWLC 1MG INJ (350MG/7ML),4303080,CDM,636,RC,J9119,HCPCS,Outpatient,,,0.01,0.01,,95.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,48.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.22,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,61.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,95.29,
CEFADROXIL 500MG CAPSULE,4303088,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETHOSUXIMIDE 250MG CAPSULE,4303093,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFADROXIL 250/5ML 100ML,4303094,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATAZANAVIR 150MG CAP,4303096,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EMTRICITABINE 200MG CAP,4303097,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE 400MG SYRINGE,4303098,CDM,636,RC,J0401,HCPCS,Outpatient,,,0.01,0.01,,24.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.87,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,15.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,6.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,24.14,
PREGABALIN 50MG CAP,4303102,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREGABALIN 75MG CAP,4303103,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXMEDETOMIDINE IN NS 400 MCG/100 ML,4303104,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HCTZ/TRIAMTERENE 25/37.5,4303110,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOL CR 0.025% 80GM,4303123,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COLESTIPOL 5GM PACK CAP,4303128,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN ETH. 200/5ML 100ML,4303156,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN ETH. 400MG,4303168,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE ACETATE 0.12% DROPS,4303188,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN NOVOLOG MIX 70/30 1 UNIT,4303203,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE SA 10MG,4303205,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FILGRASTIM 300MCG 1ML,4303209,CDM,636,RC,J1442,HCPCS,Outpatient,,,0.01,0.01,,3.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.46,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,2.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.99,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3.5,
TRIAMCINOLONE CREAM 0.025% 15GM,4303210,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICAFUNGIN 100MG INJ,4303211,CDM,636,RC,J2248,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE OINT 0.025% 15GM,4303212,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SITAGLIPTIN 25MG TAB,4303213,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVASTIGMINE 4.6MG/PATCH,4303214,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EXEMESTANE 25MG TAB,4303221,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FACTOR IX RECOMB 1 UNIT,4303223,CDM,636,RC,J7195,HCPCS,Outpatient,,,0.01,0.01,,6.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,6.15,
FACTOR IX RECOMB 1 UNIT 500 UNITS VIAL,4303224,CDM,636,RC,J7194,HCPCS,Outpatient,,,0.01,0.01,,5.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5.69,
PHENYLEPHRINE 1/8% 0.5OZ,4303225,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SITAGLIPTIN 50MG TAB,4303232,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 1MG INJ,4303236,CDM,636,RC,J9358,HCPCS,Outpatient,,,0.01,0.01,,93.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,47.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,60.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,93.38,
CRIZANLIZUMAB-TMCA 5 MG INJ (100MG),4303237,CDM,636,RC,C9053,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPENTOLATE 1% DROPS 5ML,4303238,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARGATROBAN 100MG/ML 2.5ML,4303243,CDM,636,RC,J0883,HCPCS,Outpatient,,,0.01,0.01,,4.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,4.28,
GALANTAMINE 16MG ER CAP,4303246,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE 6MG TAB,4303249,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KEY22,4303250,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
PALIPERIDONE PALMITATE 1MG (156MG) INJ,4303251,CDM,636,RC,J2426,HCPCS,Outpatient,,,0.01,0.01,,50.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,32.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,50.76,
KEY INVESTIGATIONAL MED,4303252,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
EPINEPHRINE 1MG INJ (30ML),4303253,CDM,636,RC,J0171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD BICARBONATE 4% 5ML,4303256,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE BUTYRATE 0.1% 15 GR CRM,4303264,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMBROLIZUMAB 1MG INJ (100MG VIAL),4303266,CDM,636,RC,J9271,HCPCS,Outpatient,,,0.01,0.01,,199.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,101.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,129.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,199.69,
LATANOPROST .005% 2.5ML,4303269,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLVAPTAN 15MG TABLET,4303273,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 50MG TAB UD,4303277,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 100MG TAB UD,4303278,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 10MG/ML 60ML,4303294,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 17.5MG TAB,4303295,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 6MG TAB,4303298,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMITRIPTY HCL 10MG TAB UD,4303306,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMITRIPT HCL 25MG TAB UD,4303308,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON 4MG/5ML ORAL SOLN,4303309,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMITRIPTY HCL 50MG TAB UD,4303310,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMITRIPTYLINE 75MG U/D,4303312,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMITRIPTYLINE 100MG U/D,4303314,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NORFLURANE-HFC 245FA,4303315,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARBONATE 2.5 MEQ/5 ML VIAL,4303317,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REMDESIVIR 100 MG INJ 20 ML *PT ASSIST*,4303318,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUTEROL HFA 90MCG/ACTUATION INHALER,4303321,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"AMYLS/ LIPS/ PROTEAS 15K/ 3K/9,500 UNITS",4303322,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BOTULINUM TOXIN A 100UNIT,4303326,CDM,636,RC,J0585,HCPCS,Outpatient,,,0.01,0.01,,22.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,22.4,
OMNIPAQUE 180 20ML INJ,4303327,CDM,636,RC,Q9965,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACETAM IN NACL 500MG/100ML,4303336,CDM,636,RC,J1953,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTRASE 250MG CAPSULE,4303339,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATROPINE 0.1MG/ML 10ML SYRINGE,4303340,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
USTEKINUMAB 1MG INJ (45MG/0.5ML),4303357,CDM,636,RC,J3357,HCPCS,Outpatient,,,0.01,0.01,,536.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,151.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,272.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,530.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,348.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,536.16,
USTEKINUMAB 1MG INJ (90MG/ML),4303358,CDM,636,RC,J3357,HCPCS,Outpatient,,,0.01,0.01,,536.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,151.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,272.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,530.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,348.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,151.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,536.16,
USTEKINUMAB 1MG INJ (130MG/26ML),4303359,CDM,636,RC,J3358,HCPCS,Outpatient,,,0.01,0.01,,44.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,22.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.17,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,29.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,44.67,
IMMUNE GLOBULIN 500MG (20GM/200ML),4303367,CDM,636,RC,J1561,HCPCS,Outpatient,,,0.01,0.01,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,174.38,
IMMUNE GLOBULIN 500MG (10GM/100ML),4303368,CDM,636,RC,J1561,HCPCS,Outpatient,,,0.01,0.01,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,174.38,
IMMUNE GLOBULIN 500MG (2.5GM/25ML),4303369,CDM,636,RC,J1561,HCPCS,Outpatient,,,0.01,0.01,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,174.38,
EPHEDRINE 50M /ML AMPUL,4303372,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAL CARB/VIT D 600/400 TA,4303392,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPINEPHRINE 10ML SYRINGE,4303401,CDM,636,RC,J0171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPSOM SALT,4303412,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN 333MG U/D,4303443,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN 250MG U/D,4303448,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN 500MG EC,4303450,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN 250MG BASE,4303454,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERYTHROMYCIN OPHTH 1GM,4303480,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOCILIZUMAB 1MG INJ (80MG VIAL),4303503,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
TOCILIZUMAB 1MG INJ (400MG VIAL),4303504,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
OLARATUMAB 10MG INJ (190MG VIAL),4303505,CDM,636,RC,J9285,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRADIOL 0.1MG PAT,4303511,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRADIOL 2MG TAB,4303512,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRAMUSTINE PHOS SOD,4303513,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE LIPOSOME(PF)1MG(266MG/20ML)I,4303514,CDM,636,RC,C9290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRICHLOROACETIC ACID 80%,4303515,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRADIOL 1MG TAB,4303517,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ME-TESTOSTERONE/ESTRO. TAB H.S.,4303523,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZOXIDE 50MG/ML 30ML,4303524,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VILAZODONE 20MG TAB,4303525,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VILAZODONE 40MG TABLET,4303526,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KEY - SLEEP ROOM ANESTHESIA,4303527,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BUDES/FORM 160/4.5 INH,4303541,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE ACETATE 7.5MG (LUPRON),4303542,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
NARATRIPTAN 2.5 MG TABLET,4303544,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 4MG/ML 30ML PB,4303549,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTICASONE 44MCG INHALER,4303550,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLOVENT 110MCG INHALER,4303551,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINERAL OIL/PETROLATUM CREAM,4303570,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METRONIDAZOLE 50MG/ML 60ML SUSP,4303571,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPINEPHRINE PF 1MG/ML OPHTHALIMIC INJ,4303573,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAXOLOL HCL  0.25% 10ML DROP,4303581,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTAZIDIME 50MG/ML OPHTHAL DROPS,4303590,CDM,636,RC,J0713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis B vaccine,4303593,CDM,636,RC,90746,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis B vaccine,4303594,CDM,636,RC,90746,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTECAN 300MG/15ML VIAL,4303595,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis B vaccine,4303596,CDM,636,RC,90746,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
UREA 15 GM PACKET,4303597,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EYE-STREAM IRRIG SOL 30ML,4303602,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EYE-STREAM IRRIG SOL 120ML,4303604,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 5% 200ML,4303607,CDM,636,RC,J1572,HCPCS,Outpatient,,,0.01,0.01,,198.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,101.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.42,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,129.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,198.66,
LURASIDONE 80MG TAB,4303620,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOBAZAM ORAL SUSPENSION 2.5MG/ML,4303621,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIROXICAM 20MG CAP U/D,4303622,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 1.5MG U/D TAB,4303625,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SACUBITRIL/VALSARTAN 49MG/51MG TAB,4303627,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZELASTINE 0.05% 6ML OPHTH DROPS,4303628,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SACUBITRIL/VALSARTAN 24/26MG TAB,4303629,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRALIDOXIME CL 1GM VIAL,4303635,CDM,636,RC,J2730,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISMUTH SUBGALLATE USP,4303638,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS SULF DROPS 50ML,4303640,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN 10MG INJ (1000MG/100ML),4303646,CDM,636,RC,J0131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 10MG TAB,4303652,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 20MG TAB,4303654,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS FUMARATE /DOCUSATE NA UD,4303664,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN D3 5000 IU CAPSULE,4303665,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS GLUC 324MG TAB UD,4303668,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPHENIDATE ER 36MG,4303669,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS SULF 324MG TAB UD,4303670,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIVALPROEX 500MG ER TABS,4303671,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIOTHYRONINE 50MCG TABLET,4303672,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MISOPROSTOL 25MCG TABLET,4303673,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOFETILIDE 250MCG CAP,4303676,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% INJ (2ML),4303678,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOFETILIDE 125MCG CAP,4303680,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPHOSPHAMIDE 25MG TAB,4303681,CDM,636,RC,J8530,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASTRINGYN 8GM VIALS,4303682,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTROPIPATE 0.75MG TABLET,4303684,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIVALPROEX SOD 125MG TAB,4303685,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% 50ML,4303691,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIVALPROEX SOD 250MG TAB,4303693,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXAZOSIN 2MG TABLET,4303695,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ECULIZUMAB 10 MG (300MG/30ML) INJ,4303696,CDM,636,RC,J1300,HCPCS,Outpatient,,,0.01,0.01,,797.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,225.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,405.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,788.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,518.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,797.42,
DOXYCYCLINE MONO 100MG,4303697,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FIORINAL # 3 CAPSULE,4303698,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VARICELLA-ZOSTER IMM 125U,4303699,CDM,636,RC,90396,HCPCS,Outpatient,,,0.01,0.01,,7254.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2049.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3688.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7172.3,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4713.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.23,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,7254.27,
NITROPRUSSIDE 10MG 50ML INJ,4303700,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIOTHYRONINE SOD 25MCG TABLET,4303701,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASCORBIC ACID 500 MG/ML (50) INJ,4303702,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISAVUCONAZONIUM SULF 372MG VIAL,4303706,CDM,636,RC,J1833,HCPCS,Outpatient,,,0.01,0.01,,3.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.29,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,2.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3.32,
LITHIUM CARBONATE CR 450,4303709,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM CHLORIDE 200MG/ML 50ML VIAL,4303711,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METRONIDAZOLE 250MG U/D,4303714,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPRED SODSUC 125MGVL,4303715,CDM,636,RC,J2930,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GANCICLOVIR NA 500MG INJ,4303719,CDM,636,RC,J1570,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROMIPLOSTIM 12.5MCG INJ (125MCG),4303720,CDM,636,RC,J2796,HCPCS,Outpatient,,,0.01,0.01,,338.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.12,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,220.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.95,
CEFAZOLIN 1GM PREOP,4303721,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 2GM PREOP,4303722,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 3000MG IVPB,4303723,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLEET ENEMA 133ML,4303724,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE PALMITATE 1mg (234MG) INJ,4303725,CDM,636,RC,J2426,HCPCS,Outpatient,,,0.01,0.01,,50.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,32.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,50.76,
FLEET ENEMA PEDIATRIC,4303726,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRENTUXIMAB VEDOTIN 1MG (50MG) INJ,4303727,CDM,636,RC,J9042,HCPCS,Outpatient,,,0.01,0.01,,786.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,222.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,399.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,777.38,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,510.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,786.26,
FLEET MINERAL OIL ENEMA,4303728,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 25MG SUPP,4303739,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOBENZAPRINE 10MG U/D,4303740,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TROPICAMIDE 1% 3ML OPTH DROP,4303741,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TROPICAMIDE 1% 15ML OPTH DROP,4303742,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERCONAZOLE 3 VAG CR 20GM,4303743,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUDROCORTISONE 0.1MG TAB,4303744,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERCONAZOLE 3 80MG SUPP,4303745,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE PALIMATE 1MG (156MG) INJ FD,4303746,CDM,636,RC,J2426,HCPCS,Outpatient,,,0.01,0.01,,50.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,32.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,50.76,
NIVOLUMAB 40MG/ 4ML VIAL,4303750,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
NIVOLUMAB 100MG/ 10ML VIAL,4303752,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
NIVOLUMAB 1MG INJ (240MG/24ML),4303754,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
AMPHOTERICIN B 1.5MG/ML OPHTHALMIC SOLN,4303756,CDM,636,RC,J0285,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARGATROBAN 250MG/ 250ML NS,4303760,CDM,636,RC,J0883,HCPCS,Outpatient,,,0.01,0.01,,4.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,4.28,
ARGATROBAN 50MG/50ML NS,4303761,CDM,636,RC,J0883,HCPCS,Outpatient,,,0.01,0.01,,4.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,2.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,4.28,
FLUORESCEIN STRIP 1 EA,4303764,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUORESCEIN OPHT 0.6 MG 1 STRIP,4303765,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOROURACIL 500MG/10ML,4303786,CDM,636,RC,J9190,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOROURACIL 500MG INJ (1GM),4303787,CDM,636,RC,J9190,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVAROXABAN 2.5MG TAB,4303788,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUORESCEIN NA/BENOXINATE 1ML OPHTH DROP,4303790,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVAROXABAN 10 MG TAB,4303791,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVAROXABAN 15 MG TAB,4303792,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INFLUENZA TRIVAL VAC 0.5ML (18+ YRS),4303795,CDM,636,RC,90661,HCPCS,Outpatient,,,141,84.6,,,,,,Other,Not Separately reimbursable,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.5,50,,,percent of total billed charges,pays at 50% of total billed charges,98.7,70,,,percent of total billed charges,70% of total billed charges,105.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.09,126.9,
FLUOROMETHALONE 0.1% DROPS,4303796,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOROMETHALONE ACETATE 0.1% OPTH DRPS 5,4303797,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Immunization administration by a medical assistant or nurse,4303799,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Flu shot-high dose for 2019-2020 flu season given by injection for people >65,4303799,CDM,636,RC,90686,HCPCS,Outpatient,,,131.21,78.73,,79.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,50,,,percent of total billed charges,pays at 50% of total billed charges,91.85,70,,,percent of total billed charges,70% of total billed charges,98.41,75,,,percent of total billed charges,75% of total billed charges,40.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.8,102,,,Fee Schedule,102% of CMS OPPS Rate,100.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,59.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,20.17,100,,,Fee Schedule,100% of UHC Fee Schedule,91.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,51.41,230,,,Fee Schedule,230% of CMS OPPS Rate,62.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,118.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,20.17,118.09,
FOLIC ACID 1MG 0 2ML INJ,4303805,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOLIC ACID 1MG TAB UD,4303806,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOFLURANE INHALATION 100ML,4303808,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTAZIDIME 1GM VIAL INJ,4303810,CDM,636,RC,J0713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTAZIDIME/AVIBACTAM 2.5 GRAM VIAL,4303811,CDM,636,RC,J0714,HCPCS,Outpatient,,,0.01,0.01,,337.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,171.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.04,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,219.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,95.44,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,337.85,
CEFTAZIDIME 2GM VIAL INJ,4303812,CDM,636,RC,J0713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM HYALURONATE ORTHOVISC 30MG/2ML,4303813,CDM,636,RC,J7324,HCPCS,Outpatient,,,0.01,0.01,,482.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,136.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,245.26,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,476.91,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,313.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,482.36,
MULTIVITAMIN W/IRON CHILDREN CHEW,4303814,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUTEROL 3MG/IPRATROP 0.5MG  3ML NEB,4303815,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPHOTERICIN B 50MG VIAL,4303838,CDM,636,RC,J0285,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VORTIOXETINE 5MG TABLET,4303854,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SITAGLIPTIN 100MG TAB,4303857,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMBROLIZUMAB 1MG INJ FD,4303885,CDM,636,RC,J9271,HCPCS,Outpatient,,,0.01,0.01,,199.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,101.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,129.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,199.69,
"LIDOCAINE 1% W/EPI 1:200,000 10ML INJ",4303916,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENICILLIN 125MG  100ML,4303917,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"LIDOCAINE 1% W/EPI 1:100,000 30ML",4303919,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN .1% 15GM CREAM,4303920,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN .1% 15GM OINT,4303922,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 80MG/2ML VIAL-MDV,4303924,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 120MG/100ML PB,4303925,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN OPHTH 3.5GM O,4303934,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 20MG/2ML VIAL,4303936,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GAVISCON-2 TABLET CHEW,4303944,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GELATIN OPHTHAL,4303948,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GELATION SPONGE 12/7 1EA,4303952,CDM,272,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GELATION SPONGE 100 1EA,4303954,CDM,272,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOCAINE OTIC 15ML,4303969,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARATUMUMAB-HYALURONIDASE 10MG INJ(1.8G),4303970,CDM,636,RC,J9144,HCPCS,Outpatient,,,0.01,0.01,,158.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,44.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,80.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,103.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,158.68,
GENTIAN VIOLET 1% 59ML,4303982,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUETIAPINE XR 50MG TAB,4303986,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINERAL OIL 30ML,4303995,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCL SOLUTION 4050ML,4303997,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GEVRABON 15ML,4304001,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVONORGESREL 1.5MG TABLET,4304004,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRASTUZUMAB 10MG INJ FD,4304005,CDM,636,RC,J9355,HCPCS,Outpatient,,,0.01,0.01,,285.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,145.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,185.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,285.99,
PERTUZUMAB 1MG INJ FD,4304006,CDM,636,RC,J9306,HCPCS,Outpatient,,,0.01,0.01,,54.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,27.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,35.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,54.58,
GLUCAGON 1MG,4304012,CDM,636,RC,J1610,HCPCS,Outpatient,,,0.01,0.01,,663.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,337.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,656.25,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,431.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,663.75,
GLIPIZIDE 5MG TAB UD,4304014,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLIPIZIDE 10MG TAB UD,4304016,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANESTHESIA TRAY CATH LAB,4304021,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
ACETAZOLAMID 25MG ML 40ML,4304025,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYCERIN ADULT SUPP,4304026,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYCERIN INFANT SUPP,4304028,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GRIFULVIN MICRO 125/5ML,4304038,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOSPORINE 100 MG MODFD,4304051,CDM,636,RC,J7502,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 0.5MG TAB,4304053,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOTRIMAZOLE VAG CRM 45GM,4304066,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOTRIMAZOLE 7-DAY VAG TA,4304069,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Flu shot-high dose for 2019-2020 flu season given by injection for people >65,4304072,CDM,636,RC,90686,HCPCS,Outpatient,,,131.21,78.73,,79.12,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.61,50,,,percent of total billed charges,pays at 50% of total billed charges,91.85,70,,,percent of total billed charges,70% of total billed charges,98.41,75,,,percent of total billed charges,75% of total billed charges,40.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.8,102,,,Fee Schedule,102% of CMS OPPS Rate,100.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,59.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,20.17,100,,,Fee Schedule,100% of UHC Fee Schedule,91.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,51.41,230,,,Fee Schedule,230% of CMS OPPS Rate,62.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,118.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,20.17,118.09,
HEPATIT B IMMUN GLOB 1ML,4304074,CDM,636,RC,90371,HCPCS,Outpatient,,,0.01,0.01,,487.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,247.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.53,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,316.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,487.03,
TRIAZOLAM 0.125MG TAB,4304077,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERRIC CARBOXYMALTOSE 750MG/15ML VIAL,4304083,CDM,636,RC,J1439,HCPCS,Outpatient,,,0.01,0.01,,3.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,2.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3.96,
HALOPERIDOL 5MG/ML VIAL,4304084,CDM,636,RC,J1630,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL DEC 100MG/ML,4304085,CDM,636,RC,J1631,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL 2MG/ML 5ML,4304086,CDM,636,RC,J1630,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL 0.9% 10ML VIAL,4304094,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL 0.9% 20ML VIAL,4304095,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN PEDI 12MG/ML 25ML,4304103,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL .5MG TAB UD,4304104,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL 1MG TAB UD,4304106,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL 2MG TAB UD,4304108,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL 5MG TAB UD,4304110,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IXABEPILONE 15MG/KIT,4304115,CDM,636,RC,J9207,HCPCS,Outpatient,,,0.01,0.01,,451.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,229.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,293.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,451.59,
MERCAPTOPURINE 50MG TAB,4304122,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTRADIOL 0.025MG/24HR PT,4304125,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAZIQUANTEL 600MG TAB,4304151,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROPINIROLE 3MG TAB,4304153,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PACLITAXEL 30MG INJ,4304159,CDM,636,RC,J9267,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TESTOSTERONE CYP 200MG/ML,4304170,CDM,636,RC,J1071,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN  10U/ML VIAL 10ML,4304180,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCITRIOL 1MCG/ML ORAL 15ML,4304183,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 100U/ML 10ML VL,4304184,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN 1GM PACK,4304187,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 10 UNITS/ML FLUSH 1ML,4304188,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOFLOXACIN 750MG TAB,4304189,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN PF 100U/ML VL 1ML,4304190,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE LIPOSOME(PF)1MG(133MG/10ML),4304191,CDM,636,RC,C9290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN SOD (PF) 1000 UNITS/ML 2ML VIAL,4304197,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 1000U/ML VL 10ML HD,4304198,CDM,636,RC,J1644,HCPCS,Outpatient,,,58,34.8,,,,,,Other,Not Separately reimbursable,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29,50,,,percent of total billed charges,pays at 50% of total billed charges,40.6,70,,,percent of total billed charges,70% of total billed charges,43.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,46.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.09,52.2,
HEPARIN 1000U/ML VL 10ML,4304199,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 1000U/ML VIAL 1ML,4304200,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 5000U/ML VL 10ML,4304204,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 1000U/ML VL 10ML HD,4304205,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICAFUNGIN 50MG INJ,4304211,CDM,636,RC,J2248,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PYRIDOXINE 100MG/ML VIAL,4304232,CDM,636,RC,J3415,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DECITABINE 50MG VIAL,4304235,CDM,636,RC,J0894,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM NITRATE-SODIUM THIOSULFATE KIT,4304236,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORHEXIDINE GLUC .12% 15ML,4304237,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AGALSIDASE 1 MG (35MG) INJ,4304239,CDM,636,RC,J0180,HCPCS,Outpatient,,,0.01,0.01,,770.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,391.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,761.6,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,500.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,770.3,
AGALSIDASE 1 MG (5MG) INJ,4304240,CDM,636,RC,J0180,HCPCS,Outpatient,,,0.01,0.01,,770.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,391.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,761.6,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,500.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,770.3,
CEFDINIR 250MG/5ML 60ML,4304262,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETANUS IMMUNE 250.00 U,4304276,CDM,636,RC,J1670,HCPCS,Outpatient,,,0.01,0.01,,2068.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,584.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1051.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2045.36,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,584.39,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,2068.73,
BENZOCAINE 20% SPRAY 0.5ML,4304283,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOCAINE 60ML SPRAY,4304286,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMET 5ML,4304287,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYCODAN TAB,4304288,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PANTOPRAZOLE SOD DR 20MG TABLET,4304289,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE W/EPI 1% 50ML V,4304303,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"LIDOCAINE 1% / EPI 1:100,000 10ML VIAL",4304304,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDRALAZINE 10MG TAB UD,4304316,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYUREA 500MG CAP,4304326,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOFENAC 1% GEL 100GM,4304327,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCHLOROTHIAZIDE 25MG,4304328,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCHLOROTHIAZIDE 50MG,4304330,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE.5% 30GMCRM,4304336,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 1%30GMCRM,4304338,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MULTIPLE VITAMIN CHILDREN,4304341,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 1% 30GMOIN,4304342,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOTEPREDNOL 0.5% 5ML OPTH,4304345,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 10MG TAB,4304350,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 20MG TAB,4304352,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAPTOMYCIN 500MG VIAL,4304385,CDM,636,RC,J0878,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE 100MG/2ML VL,4304396,CDM,636,RC,J3410,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORTHALIDONE 25MG TABUD,4304404,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN 500MG ADV,4304411,CDM,636,RC,J0456,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BOUDREAUX BUTT PASTE 57GM,4304426,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRASTUZUMAB-HYALURON-OYSK 10 MG (600MG),4304427,CDM,636,RC,J9356,HCPCS,Outpatient,,,0.01,0.01,,233.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,118.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,66,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66,100,,,Fee Schedule,100% of CMS OPPS Rate,151.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,233.64,
TERAZOSIN HCL 5MG PO,4304435,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MARCOF BP 5ML,4304437,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZOLPIDEM TARTRATE 10MG TA,4304445,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IFOSFAMIDE 3GM VIAL,4304450,CDM,636,RC,J9208,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BLEOMYCIN 15UNITS (30UNITS) INJ,4304452,CDM,636,RC,J9040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IFOSFAMIDE 1GM VIAL,4304453,CDM,636,RC,J9208,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GAMMA GLOBULIN INJ 1ML GAMASTAN,4304459,CDM,636,RC,J1460,HCPCS,Outpatient,,,0.01,0.01,,172.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,48.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,87.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,170.69,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,112.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,48.77,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,172.64,
HEPARIN 20U/20ML VIAL,4304466,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 12.5MG TAB,4304485,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMNIPAGUE 350 100ML INJ,4304504,CDM,636,RC,Q9967,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 4MG TABLET,4304511,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINERAL OIL LIGHT STERILE 25ML,4304520,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOPERAMIDE 2MG CAP U/D,4304538,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 250 MG CAP,4304539,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 125 MG CAP,4304540,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZOLPIDEM TARTRATE 5MG TAB,4304543,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOPERAMIDE 1MG/7.5ML SOLN (120ML),4304544,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZATHIOPRINE 50MG TAB,4304550,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM HCL CD 120,4304551,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PITAVASTATIN 4MG TAB,4304552,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PITAVASTATIN 2MG TAB,4304553,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPROXEN EC 500MG TAB,4304554,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPHOTERICIN B LIPOSOMAL 10MG INJ (50MG),4304555,CDM,636,RC,J0289,HCPCS,Outpatient,,,0.01,0.01,,98.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.72,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,64.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.83,
AMPHOTERICIN B LIPOSOMAL 1MG/ML PEDI,4304557,CDM,636,RC,J0289,HCPCS,Outpatient,,,0.01,0.01,,98.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.92,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.72,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,64.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.83,
PROPRANOLOL 1MG/ML 1ML AM,4304560,CDM,636,RC,J1800,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CASIRIVIMAB 1332MG/11.1 ML INJ FD,4304564,CDM,636,RC,Q0243,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMDEVIMAB 1332MG/1.1 ML INJ FD,4304565,CDM,636,RC,Q0243,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GONAK 2.5% OPH 15ML,4304567,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MESALAMINE 400MG CAP,4304571,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZILSARTAN 40MG TABLET,4304572,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 60MG LA U/D,4304573,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INFLUENZA VAC (FLUZONE) 0.5ML 3YR AND >,4304574,CDM,636,RC,Q2038,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 80MG ER U/D,4304578,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 120MG ER U/D,4304580,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 160MG LA U/D,4304582,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANALOL 10MG TAB U/D,4304584,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 20MG TAB U/D,4304586,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 40MG U/D TAB,4304590,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CASIRIV-IMDEVIMAB 1332/1332 INJ FB,4304591,CDM,636,RC,Q0244,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL 60MG U/D TAB,4304592,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDIGO CARMINE 8MG/ML 5ML,4304606,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CUPRIC CHLORIDE 0.4 MG/ML 10ML VIAL,4304608,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDOMETHACIN 1MG INJ,4304609,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN LYS 10MG/ML 2ML,4304610,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARIPRAZINE 1.5MG CAPSULE,4304611,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDOMETHACIN 50MG SUPP,4304612,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARIPRAZINE 3MG CAPSULE,4304613,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDOMETHACIN 75MG SR UD,4304614,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALAMINE/ ZN 3 INCH BANDAGE,4304615,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDOMETHACIN 25MG CAP UD,4304616,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDOMETHACIN 50MG CAP UD,4304618,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUCCIMER 100MG CAP,4304623,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CROMOLYN 2ML UD NEB,4304634,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STREPTOZOCIN 1GM VIAL,4304636,CDM,636,RC,J9320,HCPCS,Outpatient,,,0.01,0.01,,1310.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,370.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,666.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1295.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,851.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,370.18,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1310.43,
DORZOLAMIDE HCL 2% 10ML,4304666,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISONIAZID 300MG TABLET UD,4304684,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOPROTERENOL  2MG ML 5ML,4304690,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC HEPB VAC PED DOSE IM,4304693,CDM,636,RC,90744,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC DTAP-IPV VACC IM,4304694,CDM,636,RC,90696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis A vaccination for adolescents and children,4304696,CDM,636,RC,90633,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
3-dose HPV vaccination,4304697,CDM,636,RC,90649,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC FLU VACC 6-35 MTHS DOSE IM/JET,4304698,CDM,636,RC,90657,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Preservative free flu vaccine,4304699,CDM,636,RC,90658,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC ROTAVIRUS VACC ORAL,4304700,CDM,636,RC,90680,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC DTAP VACC IM,4304701,CDM,636,RC,90700,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"Measles, mumps and rubella vaccine",4304702,CDM,636,RC,90707,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"measlesMeasles, mumps, rubella and varicella vaccine",4304703,CDM,636,RC,90710,HCPCS,Outpatient,,,0.01,0.01,,566.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,288,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,560,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of CMS OPPS Rate,368,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,566.4,
Varicella vaccine,4304705,CDM,636,RC,90716,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC TD VACC 7YRS+ IM/JET,4304706,CDM,636,RC,90714,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",4304707,CDM,636,RC,90715,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC DTAP-HEPB-IPV VACC IM,4304708,CDM,636,RC,90723,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
pneumococcal Pneumococcal vaccine,4304709,CDM,636,RC,90732,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
meningococcal Meningococcal conjugate vaccine,4304710,CDM,636,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis B vaccine,4304711,CDM,636,RC,90746,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC PNEUMOCOCCAL CONJ VAC 13 VALENT IM,4304713,CDM,636,RC,90670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACTIVASE 1MG/ML 2ML VIAL,4304714,CDM,636,RC,J2997,HCPCS,Outpatient,,,0.01,0.01,,315.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,315.62,
ALTEPLASE 1MG INJ (50MG VIAL),4304715,CDM,636,RC,J2997,HCPCS,Outpatient,,,0.01,0.01,,315.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,315.62,
CASCARA SAGRADA 450MG CAPSULE,4304716,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC DTAP-HIB-IPV VACC IM,4304717,CDM,636,RC,90698,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC HIB PRP-T CONJ VACC IM,4304719,CDM,636,RC,90648,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PILOCARPINE 1%    15ML,4304720,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYANOCOBALAMIN 1000MCG* PT OWN MED*,4304721,CDM,636,RC,J3420,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOPTO CARPINE 2% 15ML,4304722,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 2MG/ML SYRUP 1ML,4304737,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALTEPLASE 1MG (100MG VIAL),4304738,CDM,636,RC,J2997,HCPCS,Outpatient,,,0.01,0.01,,315.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,315.62,
FLUCYTOSINE 250MG CAPSULE,4304749,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCYTOSINE 500MG CAP,4304752,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METRONIDAZOLE 0.75% GEL,4304753,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAPTOPRIL 1MG/ML 50ML NSY,4304755,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE 20MG ER TAB,4304756,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE 40MG CR TAB,4304757,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMETREXED 500MG VIAL,4304759,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
ISOSORBIDE 2.5MG SL,4304774,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL BACTERIOSTATIC INJ (30ML),4304780,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE 40MG SA TAB UD,4304782,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPINEPHRINE 0.1MG (1MG/1ML) VIAL,4304784,CDM,636,RC,J0171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBID 5MG TAB U/D,4304796,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBID 10MG TAB U/D,4304798,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE 20MG TAB U/D,4304800,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOPROTERENOL  2MG ML 1ML,4304820,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCHLOROTHZ 12.5MG CAP,4304826,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVALBUTEROL 1 25MG  0 5ML,4304832,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXANDROLONE 2.5MG TAB,4304835,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GEMFIBROZIL 600MG TAB UD,4304855,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KCL 20MEQ SA TABLET U/D,4304857,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
K BICARB/CA 25MEQ EFF TAB,4304866,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RETAPAMULIN 1% OINT 15GM,4304867,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
K BICARB/CA EFFER 10MEQ TAB,4304868,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
K BICARB/CA EFFER 20MEQ TAB,4304869,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 2 MEQ/1 ML ORAL SOLN,4304870,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
K-PHOS NEUTRAL TABLET,4304872,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
K-PHOS ORIGINAL 500MG TAB,4304876,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KAOLIN-PECTIN 30ML UD,4304884,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 12MCG/HR PATCH,4304885,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 1UNIT/ML 0.45% NACL,4304888,CDM,250,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIODARONE 150MG INJ 3ML,4304889,CDM,636,RC,J0282,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASS CL SA 10MEQ U/D,4304896,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEPHALEXIN 125MG/5ML 100M,4304907,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEG ELECTROLYTE SOLN 420GM W FLAVOR,4304911,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STERILE TALC POWDER 4 GM,4304912,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROGESTERONE 8% GEL 1.125 GM,4304913,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEBTELOVIMAB 175 MG INJ FD,4304914,CDM,636,RC,Q0222,HCPCS,Outpatient,,,0.01,0.01,,8474.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2394,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4309.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8379,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,5506.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8474.76,
CIPROFLOXACIN 6% 1ML OTIC DROPS,4304915,CDM,637,RC,J7342,HCPCS,Outpatient,,,0.01,0.01,,106.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.07,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,69.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,106.27,
CEFEPIME 1 GRAM/50 ML D5W,4304917,CDM,636,RC,J0692,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEPHALEXIN 250MG/5ML 100M,4304918,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEPHALEXIN 250MG CAP U/D,4304930,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEPHALEXIN 500MG CAP UD,4304934,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OFLOXACIN OTIC 0.3% 10ML,4304939,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MILNACIPRAN 50MG TABLET,4304941,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KENALOG IN ORABASE 5GM,4304962,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE 10MG/ML 5ML,4304964,CDM,636,RC,J3301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 10MCG/ML-CAS100M,4304965,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE 40MG/ML 1ML,4304970,CDM,636,RC,J3301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VFC IPV VACCINE IM/SQ,4304973,CDM,636,RC,90713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETAMINE50MG/ML VIAL 10ML,4304976,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SINCALIDE 5MCG/ML INJ,4304988,CDM,636,RC,J2805,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPENEM/CILAS 250MG/50ML PEDI SYRNG,4304994,CDM,636,RC,J0743,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TBO-FILGRASTIM 480MCG0.8/ML INJ,4304996,CDM,636,RC,J1447,HCPCS,Outpatient,,,0.01,0.01,,1.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1.48,
TBO-FILGRASTIM 300MCG/0.5ML INJ,4304997,CDM,636,RC,J1447,HCPCS,Outpatient,,,0.01,0.01,,1.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.47,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1.48,
ESCITALOPRAM 10MG TAB UD,4305000,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BECLOMETHASONE 25GM SPRAY,4305005,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE/APAP 7.5/325,4305010,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINDANE 1% 60ML LOTION,4305012,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUTORPHANOL NASAL SPRAY,4305013,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINDANE 1% 60ML SHAMPOO,4305016,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACRI-LUBE 3.5GM OINTMENT,4305022,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYOSCYAMINE/SL 0.125MG TA,4305025,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERUMOXYTOL 510MG/17ML VIAL,4305027,CDM,636,RC,Q0139,HCPCS,Outpatient,,,0.01,0.01,,1.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,0.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1.77,
METAXALONE 800MG TAB,4305028,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLORANEX TABLET 1EA,4305032,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYALURONIDASE 1 UNIT INJ (200U/ML),4305033,CDM,636,RC,J3471,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTOBACILLUS GRANULES 1G,4305034,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANOLIN 30GM OINTMENT,4305036,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIANCINOLEONE ACETONIDE(PF) 40MG/ML INJ,4305037,CDM,636,RC,J3300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOSPORINE MOD 25MG CAP,4305039,CDM,636,RC,J7515,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLCELLULOSE 479GM (LAXATIVE),4305042,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTRIAXONE 500MG INJ,4305051,CDM,636,RC,J0696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIGOXIN .5MG/2ML AMPUL,4305054,CDM,636,RC,J1160,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROPINIROLE 2MG TAB,4305060,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIGOXIN PEDI .1MG/1ML AMP,4305062,CDM,636,RC,J1160,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIGOXIN ELIX 50MCG/ML 60M,4305064,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTAZIDIME 20MG/MLPB16ML,4305065,CDM,636,RC,J0713,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIGOXIN 0.125MG UD TABLET,4305066,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIGOXIN .25MG UD TABLET,4305068,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE 0.1% OINT 80GM,4305101,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINAGLIPTIN 5MG TAB,4305102,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 1% DROP 15ML,4305103,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 20MG/2ML VIAL,4305104,CDM,636,RC,J1940,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 40MG/4ML VIAL,4305106,CDM,636,RC,J1940,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOCAINE/MENTHOL LOZENGE,4305107,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 100MG/10ML VIA,4305108,CDM,636,RC,J1940,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE SYRUP 40MG/5ML,4305109,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 10MG/ML 120ML,4305110,CDM,636,RC,J1940,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 20MG TAB UD,4305120,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 40MG TAB UD,4305123,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FUROSEMIDE 80MG TAB UD,4305124,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BROMPHENIRAMINE 12MG / PSE 90MG CAP,4305129,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXRAZOXANE 500 MG VIAL,4305130,CDM,636,RC,J1190,HCPCS,Outpatient,,,0.01,0.01,,438.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,123.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,222.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,433.58,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,284.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,123.88,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,438.53,
LEUCOVORIN 50MG/ML VL 1ML,4305134,CDM,636,RC,J0640,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COVID-19 VAC 50MCG/0.25ML (MODERNA) BOOS,4305135,CDM,636,RC,91306,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN VAC COVID-19 (MODERNA) BOOSTER,4305135,CDM,771,RC,0064A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
ADMIN IMMUNIZ COVID-19 (PFIZER) BOOSTER,4305136,CDM,771,RC,0004A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
ADMIN VAC COVID-19 (MODERNA) BOOSTER,4305137,CDM,771,RC,0064A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
COVID-19 VAC 30MCG/0.3ML(PFIZER),4305138,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 (PFIZER) BOOSTER,4305138,CDM,771,RC,0004A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
COVID-19 VAC 50MCG/0.25ML (MODERNA) BOOS,4305139,CDM,636,RC,91306,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOPHED 4MG 4ML AMP 4ML,4305142,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NOREPINEPHRINE 8MG/250ML D5W PRODCTVTY,4305147,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
LEVOTHYROXINE .025MG TAB,4305148,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 8MG TAB,4305153,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE .125MG TAB,4305174,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAUNORUBICIN 5MG/ML 4ML VIAL,4305178,CDM,636,RC,J9150,HCPCS,Outpatient,,,0.01,0.01,,112,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,56.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.74,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,112,
HYOSCYAMINE .125MG/ML 15M,4305184,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYOSCYAMINE .125MG TAB,4305190,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYOSCYAMINE .5MG/ML 1ML A,4305192,CDM,636,RC,J1980,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIPRASIDONE 20MG VIAL,4305199,CDM,636,RC,J3486,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BROM/PSE/DHC 5ML LIQ,4305203,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYOSCYAMINE .375MG SA CAP,4305204,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORDIAZ/CLINDIN 5/2.5MG,4305210,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACETAM 500MG/50ML PEDI SYRNG,4305213,CDM,636,RC,J1953,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACTEM 1000MG TABS,4305214,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORDIAZEPOX HCL 5MG CAP,4305226,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORDIAZEPO HCL 10MG CAP,4305228,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORDIAZEPO HCL 25MG CAP,4305230,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINONIDE .05% CR 60GM,4305237,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINONIDE 0.05% SOLN 20ML,4305238,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOSFOMYCIN TROMETHAMINE 3 GRAMS PACKET,4305239,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEOSTIGMINE 1:1000 SYRINGE,4305241,CDM,636,RC,J2710,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIMERCAPROL 100MG AMP,4305247,CDM,636,RC,J0470,HCPCS,Outpatient,,,0.01,0.01,,211.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,59.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,107.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,209.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,137.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,59.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,211.72,
LIDOCAINE 50MG/5ML SYRING,4305260,CDM,636,RC,J2001,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FEBUXOSTAT 80MG TAB,4305262,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 100MG/5ML SYRIN,4305264,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ABATACEPT 125MG/ML SYRINGE,4305266,CDM,636,RC,J0129,HCPCS,Outpatient,,,0.01,0.01,,151.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,76.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.44,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,151.15,
AMITRIP/CL-DIAZEPOX12.5-5,4305276,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINCOMYCIN 300MG/ML 2ML,4305282,CDM,636,RC,J2010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACLOFEN 10MG TABLET UD,4305292,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACLOFEN 20MG TABLET UD,4305294,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN RETURN,4305313,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
LITHIUM CARB 300MG TAB UD,4305320,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LITHOBID 300MG UD TABLET,4305326,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENOXYLATE/ATROP TAB U,4305350,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINOXIDIL 2.5MG TAB U/D,4305352,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINOXIDIL 10MG TAB,4305354,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TELAVANCIN 10MG (750MG VIAL),4305355,CDM,636,RC,J3095,HCPCS,Outpatient,,,0.01,0.01,,25.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.02,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,16.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,7.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.31,
METOPROLOL5MG/5ML AMPUL,4305357,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROFURANTOIN MONO 100MG,4305361,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOPROLOL 50MG TAB UD,4305362,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOPROLOL 25MG TAB,4305363,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOPROLOL 100MG TAB,4305364,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KEY-SAFE,4305365,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
GI Lab Transport Box,4305367,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
CLOTRIMAZOLE 1% CR 15GM,4305382,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOTRIMAZOLE 1% CR 30GM,4305384,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOTRIMAZOLE 1% SOLN 10ML,4305390,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DAPTOMYCIN 1MG (500MG) INJ,4305391,CDM,636,RC,J0878,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOTRIMAZOLE/BETAMETH CR,4305394,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOXAPINE 5MG CAPSULE UD,4305406,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOXAPINE 25MG CAPSULE UD,4305410,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDAPAMIDE 2.5MG TAB U/D,4305420,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LUBRIDERM 480ML LOTION,4305424,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 5-7.5-10MG KIT,4305425,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 1MG/1ML PED SOLN,4305431,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EMTRICIT/TENOFOVIR TAB,4305433,CDM,250,RC,,,Outpatient,,,296.5,177.9,,53.37,18,,,percent of total billed charges,pays at 18% of total charges,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.25,50,,,percent of total billed charges,pays at 50% of total billed charges,207.55,70,,,percent of total billed charges,70% of total billed charges,222.38,75,,,percent of total billed charges,75% of total billed charges,148.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,237.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,207.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,296.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.46,296.5,
AMPICILLIN 25MG/ML NSY,4305435,CDM,636,RC,J0290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEMANTINE 10MG TAB,4305463,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEMANTINE XR 7MG CAPSULE,4305464,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MVI-12 2X5ML VIALS,4305466,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OLANZAPINE ZYDIS 10MG TAB,4305485,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROFURANTOIN 25MG,4305496,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROFURANTOIN 50MG U/D,4305502,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROFURANTOIN 100MG  UD,4305504,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM 1GM/2ML VIAL,4305518,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULFATE 10GM/20ML INJ,4305519,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 5000U/ML 1ML,4305526,CDM,636,RC,J1644,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAFFEINE CIT. 20MG/ML 3ML,4305555,CDM,636,RC,J0706,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MANNITOL 12.5GM/50ML VL,4305566,CDM,636,RC,J2150,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE W/E 25 50ML A,4305572,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE W E 25  30ML V,4305580,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE W/EPI 0 25 10ML VIAL,4305581,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE W/E.5% 30ML V,4305584,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE PF 0.25% 10ML,4305585,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE .25% 30ML VL,4305587,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE 0.25  50ML,4305588,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE .5% 10ML VL,4305590,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE .5% 30ML VL,4305592,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE .5% 50ML VL,4305594,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPIVACAINE  75  30ML VL,4305596,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESGIC CAPSULE,4305608,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORPROPAMIDE 100 MG UD,4305611,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EXCEDRIN EXTRA STRENGTH,4305613,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FELODIPINE 5MG ER TAB,4305614,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFOPROZIL 250MG/5ML 50ML,4305617,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% JELLY 6ML,4305622,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE HCI JELLY 2% SYRINGE,4305623,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILODOSIN 8MG CAPSULE,4305627,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOPIRAMATE 100MG TABLET,4305635,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VORICONAZOLE 1% OPHTHALMIC,4305641,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERTHROMYCIN ETH. 200MG/5,4305643,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERAZOSIN HCL 2MG,4305647,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GOLIMUMAB 1MG FOR IV USE,4305648,CDM,636,RC,J1602,HCPCS,Outpatient,,,0.01,0.01,,45.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,23.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.25,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,29.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,45.77,
GOLIMUMAB 50MG/0.5ML SUB-Q PEN INJ,4305649,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OFLOXACIN 400 MG TABLET,4305650,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIFLORASONE.05% 60GM OINT,4305652,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE  15MG/5ML,4305653,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRIMONID 0.2%/5ML OPH DRP,4305654,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LURASIDONE 40MG TAB,4305656,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"AMYLS/LIPAS/PROTS 70K/ 16,800/ 40K UNITS",4305658,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOROLAC 15MG/ML INJ,4305662,CDM,636,RC,J1885,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HCTZ/TRIAMTERENE 50/75 UD,4305664,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAXIZIDE 25MG U/D,4305665,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MCT OIL LIQUID 30ML UD,4305667,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DANAZOL 200MG CAPSULES,4305676,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MECLIZINE 12.5MG TAB U/D,4305677,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROMIPLOSTIM 500MCG INJ,4305678,CDM,636,RC,J2796,HCPCS,Outpatient,,,0.01,0.01,,338.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.12,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,220.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.95,
"LID 1%/EPI 1:200,000 30ML",4305692,CDM,636,RC,J2001,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OFLOXACIN  OTIC 0.3% 5ML,4305694,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BECLOMETHASONE DIP 7.3GM INH,4305695,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZINC GLUCONATE 50MG TAB,4305702,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGIC MOUTHWASH 190ML,4305704,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 3% 15ML,4305705,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUPRANE 240ML,4305708,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUMATRIPTAN SUCC 6MG INJ,4305710,CDM,636,RC,J3030,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 30MG/0.3ML SYR,4305711,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFEPIME 2GM/ 50mL D5W,4305712,CDM,636,RC,J0692,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BSS 500 ML,4305715,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METIPRANOLOL 0.3%,4305716,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUMATRIPTAN 25MG TAB,4305718,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 4% 160MG/4ML TOP SOLN,4305721,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPREDNISOLONE 4MG UD,4305724,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BROMALINE 5ML,4305725,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 0.25% 15ML SPRAY,4305727,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERTUZUMAB 1MG (420MG) INJ,4305731,CDM,636,RC,J9306,HCPCS,Outpatient,,,0.01,0.01,,54.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,27.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,35.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,54.58,
MEGESTROL 20MG TAB,4305734,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEGESTROL 40MG TAB,4305736,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LUBIPROSTONE 24MCG  SFGEL,4305741,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZONISAMIDE 25MG TAB,4305753,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIORIDAZINE 25MG TAB UD,4305760,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIVOLUMAB 1 MG INJ (120MG/12 ML),4305761,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
MENTHOL/CAMPHOR OINT 30GM,4305781,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENOL USP 89% SWABS,4305783,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE PCA 300MG/30ML,4305788,CDM,636,RC,J2175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE 25MG INJ,4305790,CDM,636,RC,J2175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 125MG/ 125ML D5W,4305791,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE 50MG/ML VIAL,4305792,CDM,636,RC,J2175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE 75MG/1.5ML,4305794,CDM,636,RC,J2175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE 100MG/ML VIAL,4305796,CDM,636,RC,J2175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE 50MG TABLET UD,4305798,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN OPTH 0.3% 5 ML,4305806,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TAPENTADOL 50MG TAB,4305807,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 80MG/50ML PB,4305816,CDM,636,RC,J1580,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MESALAMINE ENEMA 4GM/60ML,4305827,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PYRIDOSTIGMINE 60MG TAB,4305832,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COBICISTAT 150MG TABLET,4305842,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFENESIN 600MG TAB,4305843,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IVERMECTIN 3MG TAB,4305844,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOXETINE 10MG UD,4305845,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BELIMUMAB 10MG INJ (120MG),4305846,CDM,636,RC,J0490,HCPCS,Outpatient,,,0.01,0.01,,183.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,93.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.89,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,119.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,183.97,
BELIMUMAB 10MG INJ (400MG),4305847,CDM,636,RC,J0490,HCPCS,Outpatient,,,0.01,0.01,,183.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,93.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.89,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,119.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,183.97,
METHYLTESTOSTERONE10GMBUC,4305850,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BELIMUMAB 10 MG INJ (120 MG) FD,4305851,CDM,636,RC,J0490,HCPCS,Outpatient,,,0.01,0.01,,183.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,93.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.89,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,119.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,183.97,
BELIMUMAB 10 MG INJ (400 MG) FD,4305852,CDM,636,RC,J0490,HCPCS,Outpatient,,,0.01,0.01,,183.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,93.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.89,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,119.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,183.97,
WARFARIN 4.5MG TABLET,4305853,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 6.5MG TABLET,4305854,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AVELUMAB 10MG (200MG) INJ,4305855,CDM,636,RC,J9023,HCPCS,Outpatient,,,0.01,0.01,,321.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,163.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,209.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,321.75,
ASPIRIN 81MG TABLET,4305871,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORAL HYDRATE 250MG/2.5ML,4305873,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEXISCAN 0.1MG INJ,4305874,CDM,636,RC,J2785,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORAL HYDRATE 100MG/1ML SYRUP,4305876,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXAPROZIN 600MG TABLET,4305883,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHADONE 10MG TABLET UD,4305884,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 18MG TAB,4305887,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRIMONIDINE 0.15% 5ML,4305888,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LANSOPRAZOLE 30MG CAPSULE,4305889,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHT TET PERT 0 5ML  25 58 10,4305891,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLERGONOVINE .2MG/MLI,4305892,CDM,636,RC,J2210,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",4305893,CDM,636,RC,90715,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLERGONOVINE .2MG  UD,4305894,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 10MG/5ML,4305896,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOTREXATE 2.5MG TABLET,4305898,CDM,636,RC,J8610,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOTREXATE 50MG/2ML VIAL,4305903,CDM,636,RC,J9250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOTREXATE 50MG/2ML VIAL PF,4305904,CDM,636,RC,J9250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOTREXATE SODIUM 25MG/ML 10ML VIAL,4305905,CDM,636,RC,J9250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIFABUTIN 150MG CAP,4305906,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLENE BLUE 1% 1ML AMP,4305910,CDM,636,RC,Q9968,HCPCS,Outpatient,,,0.01,0.01,,26.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.21,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,26.51,
METHYLENE BLUE 1% 10MLAMP,4305912,CDM,636,RC,Q9968,HCPCS,Outpatient,,,0.01,0.01,,26.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.21,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,26.51,
METHYLENE BLUE 0.5% 10ML INJ,4305913,CDM,636,RC,Q9968,HCPCS,Outpatient,,,0.01,0.01,,26.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.21,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,17.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,26.51,
LEVOFLOXACIN  250MG/50ML,4305916,CDM,636,RC,J1956,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFAC SOD/SULFUR LOT,4305917,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOVASTATIN 20MG TAB U/D,4305925,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SPIRONALACTON 5MG/ML 50ML,4305928,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEXILETINE 150MG TAB U/D,4305929,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTOBACILLUS RHAMNOSUS  5 BILLION CELLS,4305930,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFEPIME 2GM PB,4305936,CDM,636,RC,J0692,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISDEXAMFETAMINE 20MG CAP,4305941,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTOBACILLUS DROP 10ML,4305945,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTOBACILLUS DROP 5ML,4305946,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE 4MG/ML 5ML MDV,4305947,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN 600MG/4ML VL,4305952,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYBURIDE 2.5MG TAB UD,4305956,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACYCLOVIR 200MG/5ML,4305959,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYBURIDE 5MG TAB UD,4305960,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THROMBIN 20MUN SPRY KIT,4305965,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MILK OF MAGNESIA 30ML UD,4305968,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THROMBIN 5000 UNITS SPRAY KIT,4305969,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBAMAZEPINE 400 XR TAB,4305970,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VINCRISTINE 1MG/ML 1ML VL,4305973,CDM,636,RC,J9370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOLUTEGRAVIR SODIUM 50MG TABLET,4305977,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINERAL OIL STERILE 10ML,4305978,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOLUTEGRAVIR 25MG TABLET,4305979,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAZOSIN  1MG CAPSULE UD,4305990,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAZOSIN  5MG CAPSULE UD,4305994,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE .5% 15GM CR,4306000,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARSENIC TRIOXIDE 10MG/10ML,4306002,CDM,636,RC,J9017,HCPCS,Outpatient,,,0.01,0.01,,65.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,33.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,42.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,65.48,
SULFASALAZINE 0.5GM,4306003,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE SUL. 15MG TAB,4306004,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 2MG/ML 1ML INJ,4306007,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARSENIC TRIOXIDE 1MG INJ (12MG/6ML),4306008,CDM,636,RC,J9017,HCPCS,Outpatient,,,0.01,0.01,,65.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,33.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,42.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,65.48,
NIMODIPINE 30MG U/D,4306009,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINOCYCLINE 100MG CAP U/D,4306012,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANITIDINE 150MG/10ML,4306013,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINOCYCLINE 1MG (100MG) INJ,4306015,CDM,636,RC,J2265,HCPCS,Outpatient,,,0.01,0.01,,8.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.64,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2.47,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.74,
NECITUMUMAB 1MG INJ 800MG VIAL,4306016,CDM,636,RC,J9295,HCPCS,Outpatient,,,0.01,0.01,,20.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,10.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,20.3,
ROPINIROLE 0.25MG TAB,4306017,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCHOLINE 1 100 2ML,4306018,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBACHOL OPH 1.5ML VIAL,4306020,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLYCARBOPHIL 625MG TAB,4306026,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TICARCILLIN/CLAVULANATE 3.1GM VIAL,4306037,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFIXIME 100MG/5ML SUSPENSION 50ML,4306038,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRADEX OPTH DROPS 2.5ML,4306039,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRADEX OPTH OINT 3.5GM,4306041,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EDROPHONIUM CL 10MG/ML,4306042,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANTIVENIN MICRURUS FULVIUS,4306046,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HCTZ/AMILIORIDE 50/5 U/D,4306060,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE VAG CREAM 45GM,4306076,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE 100MG SUPP #7,4306080,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE 200MG SUPP #3,4306082,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGLOTICASE 8MG/ML VIAL,4306083,CDM,636,RC,J2507,HCPCS,Outpatient,,,0.01,0.01,,11706.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3307.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5952.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11574.67,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7606.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3307.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11706.95,
MICONAZOLE 2% CR 30GM,4306086,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE 2% CREAM 15GM,4306088,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ASENAPINE 10MG TAB,4306091,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHOLECALCIFEROL 1000 UNITS TAB,4306101,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE PCA 30MG/30ML,4306102,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 4 MG/ML VIAL 1ML,4306111,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 5 MG/ML VIAL 1ML,4306112,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 8MG/ML VIAL 1ML,4306114,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 10MG/ML VIAL 1ML,4306116,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 50MG INJ,4306117,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 15MG/ML VIAL 1ML,4306118,CDM,636,RC,J2270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 10MG/5ML 5ML UD,4306120,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 30MG SA TAB U/D,4306126,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN PEDI SYRNG 4MG/ML,4306127,CDM,636,RC,J3260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 800MG TAB U/D,4306136,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCYSTIENE 20% SOLUTION,4306154,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCYSTEINE 20% 30ML,4306155,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCYSTEINE 10% 4ML VL,4306158,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETYLCYSTEINE 20% 6G/30,4306166,CDM,636,RC,J0132,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MULTIVITAMIN/MINERAL LIQUID 5ML,4306169,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"MULTIVITAMIN,THER TAB UD",4306170,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENTAMICIN 0.1% 30GM OINT,4306171,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUKEMIA COCKTAIL 90ML,4306174,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BOSENTAN 125MG TAB,4306178,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MUPIROCIN 2% OINT 22GM,4306179,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MITOMYCIN 5MG VIAL,4306180,CDM,636,RC,J9280,HCPCS,Outpatient,,,0.01,0.01,,338.45,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,334.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,219.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.45,
FILGRASTIM BIOSIMILAR 300MCG/0.5ML,4306182,CDM,636,RC,Q5101,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FILGRASTIM BIOSIMILAR 480MCG/0.8ML,4306183,CDM,636,RC,Q5101,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETHAMBUTOL 400MG U/D,4306192,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILATERIA (LAMINARIA),4306193,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN SUSP 25MG/ML (1ML),4306194,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 10% 0.5 GM,4306196,CDM,636,RC,J1572,HCPCS,Outpatient,,,0.01,0.01,,198.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,101.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,196.42,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,129.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,198.66,
AMOXICILLIN SUSP 50MG/ML (1ML),4306197,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLN/CLAV  SUSP 80MG/11.4MG/ML 1ML,4306198,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN SUSP 20MG/ML (1ML),4306199,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZITHROMYCIN SUSP 40MG/ML (1ML),4306200,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFADROXIL SUSP 50MG/ML (1ML),4306201,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFDINIR SUSP 50MG/ML (1ML),4306202,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFPROZIL SUSP 50MG/ML (1ML),4306203,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEPHALEXIN SUSP 50MG/ML (1ML),4306204,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLARITHROMYCIN SUSP 50MG/ML (1ML),4306205,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCUSATE SODIUM SOLN 10MG/ML (1ML),4306206,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONASOLE SUSP 10MG/ML (1ML),4306207,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONASOLE SUSP 40MG/ML (1ML),4306208,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFENESIN SOLN 20MG/ML (1ML),4306209,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LACTULOSE 0.67MG/ML (1ML),4306210,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORATIDINE SOLN 1MG/ML (ML),4306211,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMANTADINE SOLN 10MG/ML (1ML),4306212,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CARBONATE SUSP 100MG/ML (1ML),4306213,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATOVAQUONE SUSP 150 MG/ML (1ML),4306214,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISMUTH SUBSALICYLATE SUSP 17.5MG/ML 1ML,4306215,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBAMAZEPINE SUSP 20 MG/ML(1ML),4306216,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROMETHOR-GUAIFN SYRP 2MG/20MG/ML 1ML,4306217,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOXETINE SOLN 4MG/ML (1ML),4306218,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYPROHEPTADINE SYR 0.4 MG/ML (1ML),4306219,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROMETHORPHAN SYR 1MG/ML (1ML),4306220,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON SOLN 0.8MG/ML (1ML),4306221,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOPERAMIDE SUSP 0.13MG/ML (1ML),4306222,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXCARBAZEPINE SUSP 60MG/ML (1ML),4306223,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"NYSTATIN SUSP 100,000 UNITS/ML (1ML)",4306225,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN SUSP 25MG/ML (1ML),4306226,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALUM-MAG HYDROXIDE-SIMETHICONE 1ML,4306227,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUCRALFATE SUSP 100MG/ML (1ML),4306228,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALPROIC ACID SYR 50MG/ML (1ML),4306229,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN W/TRIAMCIN 15GM,4306230,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLOROTHIAZIDE SUSP 50MG/ML (1ML),4306231,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN/TRIAMCIN OINT 15,4306232,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN SUSP 50MG/ML (1ML),4306233,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN PALMITATE SOLN 15MG/ML (1ML),4306234,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN SUSP 20MG/ML (1ML),4306235,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LINEZOLID SUSP 20MG/ML (1ML),4306236,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOMETHYLFOLATE 15MG CAPSULE,4306237,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OSELTAMIVIR 6MG/ML (1ML),4306239,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE-CODEINE 1.25MG/2MG/ML (1ML),4306240,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPREN/NALOX 2-0.5MG TAB,4306241,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEDIARIX VACCINE,4306242,CDM,636,RC,90723,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN-CODEINE 24MG/2.4MG/ML 1ML,4306243,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CODEINE-GUAIFENESIN 2MG/20MG/ML (1ML),4306244,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POVIDONE-IODINE,4306245,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PARICALCITOL 1MCG CAP,4306246,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 0.5% OINT 30GM,4306247,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN POWD 15GM,4306248,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFAMETHOX-TMP SUSP 40MG/8MG/ML (1ML),4306249,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCODONE-ACETAM 0.5MG/21.7MG/ML (1ML),4306251,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDRAMINE ELIX 2.5MG/ML (1ML),4306252,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 2.5% 3ML,4306257,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 2.5% 2ML DROP,4306259,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TROPICAMIDE 1% 1ML OPHTH DROP,4306263,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAALOX PLUS ES 30ML UD,4306274,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMETHICONE 40MG/.6ML 30M,4306288,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACLOFEN INTERTRECAL 50MCG (1ML) INJ,4306289,CDM,636,RC,J0476,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DENOSUMAB 1MG (60MG) SYR **FD**,4306290,CDM,636,RC,J0897,HCPCS,Outpatient,,,0.01,0.01,,85.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.77,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,55.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,85.73,
HYDROXYUREA 1000MG TABLET,4306293,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMETHICONE 80MG TAB U/D,4306296,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARTHRITIS PAIN MED 120GM,4306300,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COVID-19 VAC LIQUID 30MCG/0.3ML (PIFIZER,4306301,CDM,636,RC,91305,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) B,4306301,CDM,771,RC,0054A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
COVID-19 VAC LIQUID 30MCG/0.3ML (PIFIZER,4306302,CDM,636,RC,91305,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) 1,4306302,CDM,771,RC,0051A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
COVID-19 VAC LIQUID 30MCG/0.3ML (PIFIZER,4306303,CDM,636,RC,91305,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) 2,4306303,CDM,771,RC,0052A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
COVID-19 VAC LIQUID 30MCG/0.3ML (PIFIZER,4306304,CDM,636,RC,91305,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) 3,4306304,CDM,771,RC,0053A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
COVID-19 VAC LIQUID 30MCG/0.3ML (PIFIZER,4306305,CDM,636,RC,91305,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) B,4306306,CDM,771,RC,0054A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) 1,4306307,CDM,771,RC,0051A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) 2,4306308,CDM,771,RC,0052A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
ADMIN IMMUNIZ COVID-19 LIQUID (PFIZER) 3,4306309,CDM,771,RC,0053A,HCPCS,Outpatient,,,76.56,45.94,,13.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,13.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,38.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.78,68.9,
PRIMIDONE 50MG TAB,4306310,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRIMIDONE 250MG TAB U/D,4306314,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATEZOLIZUMAB 10 (1200MG/20ML) INJ,4306315,CDM,636,RC,J9022,HCPCS,Outpatient,,,0.01,0.01,,292.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,148.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.17,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,190.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,292.47,
ATEZOLIZUMAB 10MG INJ (840MG/14ML),4306316,CDM,636,RC,J9022,HCPCS,Outpatient,,,0.01,0.01,,292.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,148.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.17,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,190.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,292.47,
ZINC SULFATE 10MG/10ML,4306325,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPILIMUMAB 50MG VIAL,4306327,CDM,636,RC,J9228,HCPCS,Outpatient,,,0.01,0.01,,596.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,303.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,387.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,596.7,
IPILIMUMAB 200MG VIAL,4306328,CDM,636,RC,J9228,HCPCS,Outpatient,,,0.01,0.01,,596.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,303.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,387.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,596.7,
Shingles vaccine,4306329,CDM,636,RC,90736,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBANDRONATE 150MG TABLET,4306357,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPROSARTAN 600MG TAB,4306358,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROPIVACAINE 0.5% 30ML INJ,4306368,CDM,636,RC,J2795,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROPIVACAINE 0.5% INJECTION,4306369,CDM,636,RC,J2795,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPHCON-A OPH 15ML,4306370,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBEPOETIN 1MCG (60MCG) INJ,4306371,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
CHLOROTHIAZIDE 250MG TABLET,4306372,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPROXEN 250MG TABLET UD,4306378,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPROXEN 375MG TABLET UD,4306380,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 20mEq POWDER PKT,4306381,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPROXEN 500MG TABLET UD,4306382,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIPERONYL BUTOXIDE - PYRETHRUM SHAMPOO,4306383,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERIBULIN MESYLATE 0.1MG INJ,4306385,CDM,636,RC,J9179,HCPCS,Outpatient,,,0.01,0.01,,463.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,130.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,235.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,458.04,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,301,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,463.27,
NALOXONE HCL 0.4MG/ML 1ML,4306386,CDM,636,RC,J2310,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOSAPREPITANT DIME. 150MG,4306387,CDM,636,RC,J1453,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
APREPITANT 1MG INJ (130MG VIAL),4306391,CDM,636,RC,J0185,HCPCS,Outpatient,,,0.01,0.01,,6.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,6.15,
NASALCROM 4% SPRAY 13ML,4306394,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOLIFENACIN 5MG TABLET,4306398,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE 20MG/ML UD 1ML,4306412,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIOTHIXENE CAP 1MG U/D,4306444,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERROUS SULFATE ELIX 44MG/ML (1ML),4306445,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GRISEOFULVIN SUSP 25MG/ML (1ML),4306447,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIOTHIXENE 5MG CAP U/D,4306448,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE SOLN 5.3MG/ML (1ML),4306449,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIOTHIXENE 10MG CAP U/D,4306450,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HALOPERIDOL SOLN 2MG/ML (1ML),4306451,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE HCL SYRP 2MG/ML (1ML),4306453,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LITHIUM CITRATE SOLN 60MG/ML (1ML),4306455,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN INJ 80.00 MG,4306456,CDM,636,RC,J3260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MULTIVITAMINS-MINERALS-IRON SOLN (1ML),4306457,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE SYRP 1.25MG/ML (1ML),4306458,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETH-PHENYLEPH SYRP 1.25/1MG/ML (1ML),4306459,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAIR HAIR REMOVAL CRM 8OZ,4306460,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPRANOLOL SOLN 4MG/ML (1ML),4306461,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEDIUM CHAIN TRIGLYCER OIL (1ML),4306462,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM GLUB 115MG/5ML,4306491,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE NITRATE 2% OINT 56GM,4306492,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFUROXIME 250MG/5ML SUSP 100ML,4306493,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DURVALUMAB 10MG INJ FD,4306520,CDM,636,RC,J9173,HCPCS,Outpatient,,,0.01,0.01,,282.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,143.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.08,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,183.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,282.27,
MICONAZOLE 2% OINT 5OZ,4306521,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATOMOXETINE 10MG CAP,4306524,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LET 10ML SYRINGE,4306526,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACET 500MG/5ML VL,4306528,CDM,636,RC,J1953,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1000MG VIAL,4306529,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 0.25% 15ML DROPS,4306534,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 0.5% 15ML,4306536,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1000MG ADV,4306537,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZINC CHLORIDE 1 MG/ML 10ML VIAL,4306538,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPH HCL 10% 5ML GTT,4306540,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GI COCKTAIL,4306541,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 10MG/ML AMP,4306542,CDM,636,RC,J2370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVETIRACTEM 500MG/5ML LQ,4306547,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE 20MCG/ML,4306549,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISDEXAMFETAMINE 70MG CAP,4306552,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEOMYCIN 500MG TABLET UD,4306558,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERSANTINE 5MG/ML 2ML,4306559,CDM,636,RC,J1245,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FELODIPINE 2.5MG ER TAB,4306560,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYPROMELLOSE  0.5% OPTH,4306561,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEO/BACI/POLY .94GM O PCK,4306562,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE (LUPRON 11.25MG) PER 3.75MG,4306563,CDM,636,RC,J1950,HCPCS,Outpatient,,,0.01,0.01,,5396.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2743.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5335.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3505.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5396.16,
NEO/BACI POLY 15GM OINT,4306564,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEO/BACI/POLY OPH 10ML,4306570,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE (LUPRON 22.5MG) PER 7.5MG,4306571,CDM,636,RC,J9217,HCPCS,Outpatient,,,0.01,0.01,,590.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,300.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,583.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,383.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,590.08,
NEO/BACI/POLY 3.7GM OPH O,4306572,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXMETHYLPHEN XR 10MG CAP,4306573,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VARENICLINE 0.5MG TAB,4306574,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RISPERIDONE 0.25MG TABLET,4306575,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEOSTIGMINE 1:2000 0.5MG/ML,4306579,CDM,636,RC,J2710,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEOSTIGMINE 1:1000 0.5MG INJ,4306580,CDM,636,RC,J2710,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHAZOLAMIDE 50MG TAB,4306582,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN 80 MG INJ 30ML,4306583,CDM,636,RC,J3260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLOROPROCAINE PF 2% INJECTION,4306588,CDM,636,RC,J2400,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IXABEPILONE 45MG/KIT,4306589,CDM,636,RC,J9207,HCPCS,Outpatient,,,0.01,0.01,,451.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,229.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,293.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,451.59,
CHLOROPROCAINE PF 3% 20ML,4306590,CDM,636,RC,J2400,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEBTELOVIMAB 175 MG (2ML) NJ,4306604,CDM,636,RC,Q0222,HCPCS,Outpatient,,,0.01,0.01,,8474.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2394,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4309.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8379,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,5506.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,2394,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8474.76,
FENOFIBRATE 145 MG TAB,4306606,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIACIN 50MG TABLET,4306610,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIACIN 100MG TABLET,4306612,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE 75MCG TAB,4306632,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICOTINE 2MG,4306636,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN 500MU TAB U/D,4306642,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN CREAM 15GM,4306644,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN/TRIAMCINOLONE 30GM CREAM,4306645,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN 15GM OINT,4306646,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN CREAM 30GM,4306647,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYTARABINE LIPOSOME 50MG,4306650,CDM,636,RC,J9098,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROPRUSSIDE 50MG 100ML NS INJ,4306651,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROPRUSSIDE 50MG VIAL,4306652,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN 10% 50ML,4306653,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
IMMUNE GLOBULIN 10% 200ML,4306654,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
IMMUNE GLOBULIN 10% 400ML,4306655,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
AMLODIPINE 10MG TAB,4306657,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMLODIPINE 5MG TAB,4306658,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROPIVACAINE1%10MG/ML 10ML,4306667,CDM,636,RC,J2795,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NTG 5MG PATCH,4306668,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRINZOLAMIDE 1% 10ML,4306674,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FOSINOPRIL 20MG TAB,4306675,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 10MG/ML (PF) INFUMORPH,4306678,CDM,636,RC,Q9974,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RAMIPRIL 2.5MG CAPSULE,4306679,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN 2.5MG CAPUD,4306680,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALTACE 5MG CAPSULE,4306681,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WINTERGREEN OIL 2 OZ.,4306685,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINAPRIL 5MG TABLET,4306686,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN SL SPRAY,4306687,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN 2% OINT PAT,4306688,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN OINT 2% 30GM,4306690,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN .3MG SL 100,4306697,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROSTAT .4MG SL,4306698,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN .6MG SL,4306699,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ETODOLAC XL 400MG,4306700,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRANDOLAPRIL 2MG TABLET,4306702,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOCONAZOLE 2% 15GM CR,4306703,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOCONAZOLE 200MG TAB,4306704,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CROTALIDAE POLYVALENT IMMUNE FAB 1 VIAL,4306705,CDM,636,RC,J0840,HCPCS,Outpatient,,,0.01,0.01,,7350.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2076.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,3737.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7267.61,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,4775.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,7350.66,
NO RINSE SHAMPOO 2OZ,4306706,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLARITHROMYCIN 500MG TAB,4306707,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICODERM 14MG PATCH,4306708,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICODERM 21MG PATCH,4306709,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICODERM 7MG PATCH,4306710,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CROTALIDAE ANTIVENIN 120MG INJ (10ML),4306711,CDM,636,RC,J0841,HCPCS,Outpatient,,,0.01,0.01,,3941.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1113.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2004.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3897.28,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2561.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.51,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3941.82,
TEMSIROLIMUS 1MG INJECTION,4306713,CDM,636,RC,J9330,HCPCS,Outpatient,,,0.01,0.01,,105.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,29.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,53.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.88,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,105.06,
ASENAPINE 5MG TABLET,4306715,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LORAZEPAM 4MG/ML 10ML VL,4306718,CDM,636,RC,J2060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TAMOXIFEN 10MG TAB,4306724,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VECURONIUM 10MG INJ VL,4306726,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ORPHENADRINE 30MG/ML 2ML,4306728,CDM,636,RC,J2360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ORPHENADRINE 100MG TAB SA,4306730,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
5FU PROLONGED CHEMOTHERAPY,4306735,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
ANIDULAFUNGIN 1MG INJ,4306742,CDM,636,RC,J0348,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LABETALOL 5MG/ML 20ML INJ,4306743,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LABETALOL 200MG TABLET UD,4306746,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LABETALOL 300MG TABLET,4306748,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LABETALOL 100MG TABLET UD,4306749,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NTG 0.2MG/ML INJ,4306750,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESIPRAMINE 10MG TAB,4306766,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE JELLY 2% 30ML,4306767,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESIPRAMINE 25MG TAB,4306778,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESIPRAMINE 50MG TAB U/D,4306780,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LABETOLOL 20MG/4ML  SYRIN,4306781,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADO-TRASTUZUMAB EMTANSINE 1MG (100MG)INJ,4306789,CDM,636,RC,J9354,HCPCS,Outpatient,,,0.01,0.01,,135.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,69.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,135.72,
ADO-TRASTUZUMAB EMTANSINE 1MG (160MG)INJ,4306790,CDM,636,RC,J9354,HCPCS,Outpatient,,,0.01,0.01,,135.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,69.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,135.72,
CIPROFLOX/DEXAMETH OTIC,4306799,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NALBUPHINE 10MG/ML 1ML,4306818,CDM,636,RC,J2300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NALBUPHINE 20MG/ML 1ML,4306820,CDM,636,RC,J2300,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIBUCAINE 1% OINT 30GM,4306840,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMVASTATIN 20MG TAB,4306845,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NICARDIPINE 20MG/200ML,4306846,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LETROZOLE 2.5MG TAB,4306848,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 4% 2.5ML INH,4306857,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCEAN NASAL 45ML SPRAY,4306864,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLURBIPROFEN .03% 2.5ML,4306865,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESTROPIPATE 1.25MG TAB,4306872,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OMEGA-3 FATTY ACID CAP,4306879,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN 1000MG INJ VL,4306880,CDM,636,RC,J0290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN 2000MG INJ VL,4306882,CDM,636,RC,J0290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANESTHESIA TRAY,4306883,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
ACCESS FRIDGE,4306884,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
KEY PCA,4306885,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
AMPICILLIN 125MG VIAL INJ,4306886,CDM,636,RC,J0290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENOXAPARIN 150MG 1ML,4306887,CDM,636,RC,J1650,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN 250MG VIAL INJ,4306888,CDM,636,RC,J0290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMPERATURE LOG,4306889,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
AMPICILLIN 500.00MG VIAL,4306890,CDM,636,RC,J0290,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PATIENT HOME MED,4306891,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
FMS - fecal management system,4306892,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
ANEST TRAY(USED),4306893,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
VINCRISTINE 1MG/ML 2ML,4306894,CDM,636,RC,J9370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FETAL DOPPLER,4306896,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
NICU TRANSPORT BOX,4306898,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BENZOCAINE 7.5% 10GM GEL,4306916,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 8.5MG TABLET,4306947,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LUBIPROSTONE 8MCG CAP,4306952,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM OXIDE 400 MG,4306959,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIAMCINOLONE 0.1% OINT 454GM,4306981,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CASPOFUNGIN 70MG VIAL,4306985,CDM,636,RC,J0637,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOFLOXACIN 500MG INJ,4306989,CDM,636,RC,J1956,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 100MG/5ML 5MLCP,4306990,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESOXIMETASONE .25% 60GM,4306991,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 6MG PCA,4306993,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGFILGRASTIM 0.5MG (6MG/0.6ML),4307002,CDM,636,RC,J2506,HCPCS,Outpatient,,,0.01,0.01,,265.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,74.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,134.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,172.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,265.32,
CAPECITABINE 500MG TAB,4307005,CDM,636,RC,J8521,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITA B12/B6/FA,4307008,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITA B12/C/FE/FA CAP,4307009,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAVASTIN 40MG TAB,4307012,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAVASTATIN 20MG TAB,4307013,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MONTELUKAST 5MG CHEWABLE,4307014,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXCARBAZEPINE 300MG/5ML,4307015,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NORTRIPTYLINE 10MG U/D,4307016,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBEPOETIN ALFA 1 MCG (25MCG) INJ ESR,4307017,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
NORTRITYLINE 25MG U/D,4307018,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMMUNE GLOBULIN (HUM) 10% FD,4307020,CDM,636,RC,J1561,HCPCS,Outpatient,,,0.01,0.01,,174.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,88.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,113.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,49.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,174.38,
DUPILUMAB 300MG/2ML INJ,4307021,CDM,636,RC,C9399,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GOLIMMUMAB 1MG (50MG) INJ FD,4307022,CDM,636,RC,J1602,HCPCS,Outpatient,,,0.01,0.01,,45.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,23.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.25,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,29.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,45.77,
DARBEPOETIN ALFA 1 MCG (60MCG) INJ ESR,4307023,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
ADHESIVE (MASTISOL),4307025,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMYLAS/ LIPAS/ PROTAS 27K /5K /17K UNITS,4307026,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBEPOETIN ALFA 1MCG (100MCG) INJ ESP,4307027,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
DARBEPOETIN ALFA 1MCG (200MCG) INJ ESP,4307028,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
DARBEPOETIN ALFA 1MCG (300MCG) INJ ESP,4307029,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
DARBEPOETIN ALFA 1MCG (500MCG) INJ ESP,4307030,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
BORTEZOMIB 0.1MG (3.5MG) INJ,4307031,CDM,636,RC,J9041,HCPCS,Outpatient,,,0.01,0.01,,8.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.1,
ZIV-AFLIBERCEPT 200MG/8ML VIAL,4307033,CDM,636,RC,J9400,HCPCS,Outpatient,,,0.01,0.01,,27.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,14.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,27.64,
GANCICLOVIR 0.15% GEL 5GM,4307034,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYCODONE/ACETAMIN 10/325,4307035,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLORAL HYDRATE 200MG/2ML,4307036,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZIV-AFLIBERCEPT 100MG/4ML VIAL,4307037,CDM,636,RC,J9400,HCPCS,Outpatient,,,0.01,0.01,,27.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,14.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,17.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,7.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,27.64,
PAPAVERINE 30MG/ML V 10ML,4307038,CDM,636,RC,J2440,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPHETAMINE MIXTURE ER 15,4307040,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COLESEVELAM 625MG TAB,4307041,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENOBARB 20MG/5ML ELIXER,4307042,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCOSANOL 10% CREAM 2GM,4307043,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOETIN BIOSIMILAR 100UNIT (2000UNIT)INJ,4307044,CDM,636,RC,Q5105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENCICLOVIR 1% CREAM,4307045,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLADRIBINE 10MG/10 ML,4307046,CDM,636,RC,J9065,HCPCS,Outpatient,,,0.01,0.01,,59.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,30.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,59.33,
CHLORSOXAZONE 500MG TAB,4307047,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIOTHYRONINE 5 MCG TAB,4307049,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOETIN BIOSIMILAR 100UNIT (3000UNIT)INJ,4307050,CDM,636,RC,Q5105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOETIN BIOSIMILAR 100UNIT (4000UNIT)INJ,4307051,CDM,636,RC,Q5105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPRATROPIUM 0.06% NASAL SPRAY 15ML,4307052,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEPAFENAC 0.3% OPHTH SUSP 3ML,4307053,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXCARBAZEPINE 150MG TABLET,4307054,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN BIOSIMILAR 100UNIT(10,000UNIT)IN",4307057,CDM,636,RC,Q5105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVAROXABAN 20 MG TAB,4307062,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN BIOSIMILAR 100UNIT(40,000UNIT)IN",4307063,CDM,636,RC,Q5105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BROMOCRIPTINE 2.5MG TAB,4307064,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPOETIN BIOSIMILAR 1000 UNIT INJ FD,4307065,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
RAVULIZUMAB-CWVZ 10MG INJ (300MG/3ML),4307066,CDM,636,RC,J1303,HCPCS,Outpatient,,,0.01,0.01,,784.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,221.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,399,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,775.84,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,509.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,784.71,
COLESTIPOL 1GM TAB,4307067,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPERIDINE PCA 10MG/ML (30ML) CSP,4307072,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHL 10MEQ/100ML,4307075,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OLANZAPINE ZYDIS 5MG,4307079,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RISPERIDONE M-TAB 0.5MG,4307089,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RISPERIDONE M-TAB 1MG,4307091,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PANCURONIUM 2MG/ML 2ML,4307092,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PANCURONIUM 1MG/ML 10ML,4307096,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NYSTATIN ORAL SUSP 5ML,4307105,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM SUSP 12MG/ML 60ML,4307119,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MESALAMINE 1GM SUPP,4307120,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACYCLOVIR 200MG CAP,4307133,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACYCLOVIR 500MG INJ VL,4307135,CDM,636,RC,J0133,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ERAVACYCLINE 1MG (50MG) VIAL,4307137,CDM,636,RC,J0122,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALLOPURINOL 100MG TAB UD,4307138,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALLOPURINOL 300MG TAB UD,4307139,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE  5 MG/5ML EL,4307141,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGFILGRASTIM-CBQV 0.5MG INJ (6MG SYR),4307142,CDM,636,RC,Q5111,HCPCS,Outpatient,,,0.01,0.01,,533.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,150.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,271.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,527.73,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,346.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,150.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,533.76,
CLINDAMYCIN 600 MG/D5W 50 ML IV,4307169,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN 900 MG/D5W 50 ML IV,4307170,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISMUTH SUBSALIC 262MG CT,4307181,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMOTIDINE 20MG TAB U/D,4307183,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RISPERIDONE M-TAB 2MG,4307184,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMOTIDINE 10MG/ML 2ML VL,4307187,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTAMIDINE 300MG SOLN,4307190,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTAMIDINE 300MG VIAL INH SOLN,4307192,CDM,636,RC,J2545,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VEDOLIZUMAB INJ 1MG (300MG VIAL),4307193,CDM,636,RC,J3380,HCPCS,Outpatient,,,0.01,0.01,,78.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,40.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.05,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,51.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,78.94,
OXYCODONE/APAP 5/325 TAB,4307194,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PSYLLIUM PCK,4307211,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZOLEDRONIC ACID 4MG/100ML,4307217,CDM,636,RC,J3489,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGASPARAGASE 3750IU/5ML INJ,4307218,CDM,636,RC,J9266,HCPCS,Outpatient,,,0.01,0.01,,91266.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,25781.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,46406.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90235.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,59297.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25781.46,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,91266.36,
CYPROHEPTADINE 2MG/5ML,4307223,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NELARABINE 50 MG (250MG/50ML) INJ,4307224,CDM,636,RC,J9261,HCPCS,Outpatient,,,0.01,0.01,,412.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,116.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,209.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,268.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,412.94,
BRILLIANT BLUE 0.25MG/ML (0.8 ML) INJ,4307236,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRILLIANT BLUE 0.5MG/ML 1ML VIAL,4307247,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MITOMYCIN 0.2MG OPTHALMIC,4307253,CDM,636,RC,J7315,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TAFLUPROST 0.0015% OPHTH SOLN,4307261,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPYRIDAMOLE 50MG TAB UD,4307262,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPYRIDAMOLE 75 MG TAB UD,4307264,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PETROLATUM 30GM JELLY,4307270,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ABSORBASE  TOPICAL,4307271,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PETROLATUM 454GM JELLY,4307272,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENICILLIN G 5MU INJ VL,4307280,CDM,636,RC,J2540,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"PENICILLIN G POT 100,000U/ML PEDI",4307281,CDM,636,RC,J2540,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE SUPP 12.5MG,4307308,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE SYRUP 5ML,4307311,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE 25MG TAB,4307314,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE 25MG SUPP,4307328,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE 50MG SUPP,4307330,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE/PE SYR 5ML,4307338,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROMETHAZINE/COD SYR 5ML,4307346,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENOBARBITAL 65MG/ML VL,4307360,CDM,636,RC,J2560,HCPCS,Outpatient,,,0.01,0.01,,128.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,36.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,65.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.87,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,128.32,
PHENOBARBITAL 130MG/ML VL,4307362,CDM,636,RC,J2560,HCPCS,Outpatient,,,0.01,0.01,,128.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,36.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,65.25,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.87,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,36.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,128.32,
PHENOBARBITAL 30MG TAB UD,4307366,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENOBARBITAL 60MG TAB UD,4307368,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENOBARBITAL 100MG TABUD,4307370,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATORVASTIN 20MG TABLET,4307372,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
URSODIOL 25MG/ML 24ML NSY,4307380,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILDENAFIL 20MG TAB,4307413,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"PNEUMOCOCCAL CONJ VAC, 13 VALENT",4307427,CDM,636,RC,90670,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PNEUMOCOCCAL CONJ VAC-20 VALENT,4307429,CDM,636,RC,90677,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE PCA 30MG/30ML,4307433,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYTOCIN 20 UNITS/1000ML LR,4307437,CDM,636,RC,J2590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYTOCIN 10U/ML AMP 1ML,4307438,CDM,636,RC,J2590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYTOCIN 20 UNITS/1000ML NS,4307439,CDM,636,RC,J2590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYTOCIN 40 UNITS/1000ML NS,4307441,CDM,636,RC,J2590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VASOPRESSIN 20U/ML 1ML,4307442,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RALTEGRAVIR 400MG TAB,4307453,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTIC/SALM 250/50 14,4307455,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUT/SALMET 500/50 14 CP,4307457,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYCHLOROQUINE 200MG/8ML SUSP,4307461,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYCHLOROQUINE 200MG,4307462,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CISPLATIN 10MG INJ,4307466,CDM,636,RC,J9060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CISPLATIN 10 MG (50MG),4307468,CDM,636,RC,J9060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN PNEUMONIA VACCINE,4307470,CDM,771,RC,G0009,HCPCS,Outpatient,,,45.5,27.3,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,31.85,70,,,percent of total billed charges,70% of total billed charges,34.13,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,34.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,31.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,74.43,100,,,Case rate,pays based on per visit rate,40.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,136.34,
pneumococcal Pneumococcal vaccine,4307470,CDM,636,RC,90732,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,50,,,percent of total billed charges,pays at 50% of total billed charges,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.06,100,,,Fee Schedule,100% of UHC Fee Schedule,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,369,
pneumococcal Pneumococcal vaccine,4307473,CDM,636,RC,90732,HCPCS,Outpatient,,,410,246,,,,,,Other,Not Separately reimbursable,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,50,,,percent of total billed charges,pays at 50% of total billed charges,287,70,,,percent of total billed charges,70% of total billed charges,307.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,328,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,70.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.06,100,,,Fee Schedule,100% of UHC Fee Schedule,287,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,369,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,64.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,369,
DEXMETHYLPHEN XR 5MG CAP,4307485,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLY-VI-FLOR.25MG/ML 50ML,4307486,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLY-VI-SOL DROPS 50ML,4307504,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLY-VI-SOL W/IRON 50ML,4307508,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN RDNA ORIGIN 1 UNI,4307510,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RAMUCIRUMAB 100MG/10ML VIAL,4307536,CDM,636,RC,J9308,HCPCS,Outpatient,,,0.01,0.01,,244.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,124.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,158.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,244.26,
RAMUCIRUMAB 500MG/50ML VIAL,4307537,CDM,636,RC,J9308,HCPCS,Outpatient,,,0.01,0.01,,244.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,124.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,158.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,244.26,
POLYMYXIN B 0.5 MU VIAL,4307544,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACI/POLYMIXIN 15GM OINT,4307548,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BACI/POLYMIXIN OPH 3.5GM,4307552,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETRACAINE 1  2ML AMPUL,4307558,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RAMIPRIL 1.25MG CAP,4307561,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETRACAINE .5% 15ML SOLN,4307562,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISINOPRIL 40MG TAB,4307566,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM ACET 2MEQ/ML VL,4307568,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 2 MEQ INJ 5ML,4307570,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHL 20MEQ/100ML,4307571,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 20MEQ/50 ML IV,4307573,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 40MEQ,4307574,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 2MEQ/ML (10ML) INJ,4307575,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CL 20MEQ/15MLUD,4307578,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CHLORIDE 40MEQ/100 ML IV,4307579,CDM,636,RC,J3480,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM CL 9.0GM PACKET,4307587,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM IODIDE 30ML SOL,4307588,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIFAXIMIN 200MG TAB,4307589,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIFAXIMIN 550MG TABLET,4307590,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM PHOS 15MM 5ML,4307591,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASSIUM PHOS 45MM 15ML,4307592,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE 9MG TAB,4307595,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GALANTAMINE 8MG ER CAP,4307596,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENRALIZUMAB 1 MG INJ (30 MG),4307603,CDM,636,RC,J0517,HCPCS,Outpatient,,,0.01,0.01,,603.78,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,170.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,307,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,596.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,392.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,603.78,
DARUNAVIR ETHANOLATE 600MG TAB,4307605,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE 1% 5ML DROPS,4307606,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARUNAVIR 400MG TABLET,4307607,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE SOD PHOS 1%,4307609,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OLARATUMAB 500 MG/50 ML VIAL,4307610,CDM,636,RC,J9285,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANOLAZINE 500MG TABLETS,4307624,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COVID-19 VAC 100MCG/0.5ML(MODERNA),4307625,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADMIN IMMUNIZ COVID-19 DOSE (MODERNA) 2,4307625,CDM,771,RC,0012A,HCPCS,Outpatient,,,76.56,45.94,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,50,,,percent of total billed charges,pays at 50% of total billed charges,53.59,70,,,percent of total billed charges,70% of total billed charges,57.42,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,61.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,53.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,68.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,68.9,
PREDNISONE 1MG TABLET UD,4307632,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISINOPRIL 20MG TAB,4307633,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISONE 2.5MG TAB UD,4307634,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CARBONATE 1250MG/5ML SUSP,4307635,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISONE 5MG TABLET UD,4307636,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISONE 10MG TABLET UD,4307638,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISONE 20MG TABLET UD,4307640,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISONE 50MG TABLET UD,4307644,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN 1UNIT/ML 0.225% NS FLUSH 3ML,4307649,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.45% FLUSH 3ML,4307650,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CHLORIDE 0.225% FLUSH 3ML,4307651,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ESTROGENS, CONJ .3MG TAB",4307658,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ESTROGENS, CONJ 0.45MG TABLET",4307659,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FIDAXOMICIN 200MG TABLET,4307660,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ESTROGENS, CONJ .9MG TAB",4307664,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ESTROGENS, CONJ 25MG VIAL",4307670,CDM,636,RC,J1410,HCPCS,Outpatient,,,0.01,0.01,,1318.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,670.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1303.68,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,856.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1318.57,
"ESTROGENS, CONJ .625MG TA",4307672,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ESTROGENS, CONJ 1.25MG TA",4307674,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ESTROGENS, CONJ VAG CREAM-IP",4307676,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYL/MO/SHLIVO/PET 30GM,4307682,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPH/SHARK LIVER/COC,4307684,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPENEM/CILASTATIN 250MG INJ (500MG),4307690,CDM,636,RC,J0743,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPENEM/CILASTATIN 250MG INJ (250MG),4307692,CDM,636,RC,J0743,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMM GLOB (OCTAGAM 10% 30GM),4307693,CDM,636,RC,J1568,HCPCS,Outpatient,,,0.01,0.01,,158.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,80.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,103.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,158.55,
IMM GLOB (OCTAGAM 10% 10GM),4307694,CDM,636,RC,J1568,HCPCS,Outpatient,,,0.01,0.01,,158.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,80.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,103.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,158.55,
IMM GLOB (OCTAGAM 10% 5GM),4307695,CDM,636,RC,J1568,HCPCS,Outpatient,,,0.01,0.01,,158.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,80.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,103.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,158.55,
AMPICILLIN 125MG/5ML 100ML,4307700,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPAFENONE HCL 150MG,4307707,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN250MG/5ML 100ML,4307708,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXYCYCLINE 100MG TABLET,4307715,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN250MG CAP UD,4307716,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOXACILLIN 250MG CAP,4307717,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 60MG SR UD,4307719,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 90MG SR UD,4307721,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN 500MG CAP UD,4307722,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 120MG SR UD,4307723,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPROPION HCL 75MG,4307725,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOFENAC EPOLAMINE 1.3% PATCH,4307726,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPROPION HCL 100MG,4307727,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
URSODIOL 300MG,4307731,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
URSODIOL 250MG TAB,4307732,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOROLAC 30MG/ML,4307735,CDM,636,RC,J1885,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOROLAC 60MG/2ML,4307737,CDM,636,RC,J1885,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESOMEPRAZOLE 40MG IV,4307740,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMIL HCL 180MG ER,4307753,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYALURONATE SODIUM INJ,4307762,CDM,636,RC,J7321,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIFEDIPINE 10MG CAP UD,4307764,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIFEDIPINE 30MG. XL TAB,4307766,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIFEDIPINE 60MG XL TAB,4307767,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIFEDIPINE 90MG XL TAB,4307768,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCHLORPERAZINE 10MG/2ML,4307780,CDM,636,RC,J0780,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAMOXINE 1% FOAM 15GM,4307784,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAMOXINE/HC RECTALFM 10G,4307786,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IODINE STRONG (LUGOLS) 5% SOLUTION,4307787,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUPHENAZINE 1MG TAB UD,4307798,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFPODOXIME 200MG TABLET,4307799,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUPHENAZINE 2 5MG ML 10M,4307806,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CAL CIT 200MG/VIT D 200IU,4307808,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUPHENAZINE DEC 25/ML 5M,4307814,CDM,636,RC,J2680,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUPHENAZINE 2.5MG TAB UD,4307818,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUPHENAZINE 5MG TAB UD,4307820,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHOLESTYRAMINE 4GM PACKET,4307825,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZOLPIDEM CR 12.5MG TAB,4307829,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MILRINONE 200MCG/ML 100ML,4307831,CDM,636,RC,J2260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Immunization administration by a medical assistant or nurse,4307833,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
INFLUENZA QUAD VACCINE (6MON+),4307834,CDM,636,RC,90688,HCPCS,Outpatient,,,116,69.6,,73.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,58,50,,,percent of total billed charges,pays at 50% of total billed charges,81.2,70,,,percent of total billed charges,70% of total billed charges,87,75,,,percent of total billed charges,75% of total billed charges,37.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.08,350,,,Fee Schedule,350% of CMS OPPS Rate,21.3,102,,,Fee Schedule,102% of CMS OPPS Rate,88.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,18.91,100,,,Fee Schedule,100% of UHC Fee Schedule,81.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,48.02,230,,,Fee Schedule,230% of CMS OPPS Rate,55.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,104.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,20.88,100,,,Fee Schedule,100% of CMS OPPS Rate,18.18,104.4,
PROMETHAZINE 25MG/ML INJ,4307836,CDM,636,RC,J2550,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RAMELTEON 8MG TAB,4307845,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCAINAMIDE 100MG/ML 10M,4307848,CDM,636,RC,J2690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROCAINAMIDE 500MG/ML 2ML,4307850,CDM,636,RC,J2690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESZOPICLONE 1MG TAB,4307862,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARY SALINE NASAL GEL,4307864,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COLLAGENASE OINT 30GM,4307868,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPYLTHIOURACIL 50MG TAB,4307872,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROPOFOL 10MG/ML  50ML,4307889,CDM,636,RC,J2704,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOTRIMAZOLE 10MG TROCHE,4307899,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 150MG TAB UD,4307922,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TENECTEPLASE 1 MG (50MG KIT),4307924,CDM,636,RC,J3101,HCPCS,Outpatient,,,0.01,0.01,,541.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,153.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,275.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,535.85,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,352.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,541.97,
BUPRENORPHINE 8MG SL TAB,4307925,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPRENORPHINE 2MG SL TAB,4307926,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STALEVO 100MG TABLET,4307986,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYALURONATE SOD 23MG/ML,4308002,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANAGRELIDE 0.5MG CAP,4308003,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Hepatitis A vaccination for adults,4308005,CDM,636,RC,90632,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMAZEPAM 7.5MG CAPSULE,4308007,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALPROSTADIL 500MCG/ML AMP,4308008,CDM,636,RC,J0270,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD.&POTASSIUM PHOS.1.25G,4308009,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROTAMINE 50MG VIAL INJ,4308010,CDM,636,RC,J2720,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PROTAMINE 10MG/ML 25ML,4308012,CDM,636,RC,J2720,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERMETHRINE 5% 60GM CREAM,4308013,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRYPAN BLUE 0.06%,4308014,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OLANZAPINE 2.5MG TAB,4308015,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBENDAZOLE 200MG TAB,4308017,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUTEROL 3ML INHALATION,4308019,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUTEROL 2MG TAB,4308020,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPATITIS B IMMUNE GL 0.5,4308021,CDM,636,RC,90371,HCPCS,Outpatient,,,0.01,0.01,,487.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,247.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.53,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,316.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,487.03,
MEDROXYPROGESTERONE 2.5,4308024,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEDROXYPROGESTERONE 10MGT,4308026,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN BIOSIMIL 1000 U (20,000U/2ML)",4308027,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
PSUEDOEPHEDRINE 30MGTABUD,4308028,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOXETINE 20MG CAP UD,4308029,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PSEUDOEPHEDRINE 60MGTABUD,4308030,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILVER NITRATE SOLN 0.5% 960ML,4308031,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISOPROLOL/HCTZ 5MG/6.25M,4308032,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OBINUTUZUMAB INJ 10MG (1000MG VIAL),4308036,CDM,636,RC,J9301,HCPCS,Outpatient,,,0.01,0.01,,248.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,70.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,126.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,161.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,70.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,248.82,
CYANOCOBALAMIN 100MCG,4308039,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MISOPROSTOL 200MCG TABLET,4308041,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PYRAZINAMIDE 500MG TABLET,4308044,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"EPOETIN BIOSIMIL 100U (20,000U/2ML) ERSD",4308046,CDM,636,RC,Q5105,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUVASTATIN XL 80MG SA TB,4308048,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOFENAC SOD 50MG,4308049,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DICLOFENAC SOD EC 75MG,4308051,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENAZOPYRIDINE 100MG UD,4308052,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENAZOPYRIDINE 200MG UD,4308054,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLURBIPROFEN 100MG TAB,4308055,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCODONE/APAP 7.5/325MG TAB,4308056,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCODONE/APAP 7.5/500,4308057,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM 64MG SA,4308059,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PYRIDOXINE 50MG TAB UD,4308060,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIAGABINE 4MG TAB,4308061,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EZETIMIBE 10MG TAB UD,4308063,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAROXETINE 20MG TAB,4308065,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAROXETINE CR 12.5MG,4308067,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAROXETINE CR 25MG,4308068,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOTIFEN 0.025% DROPS,4308069,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE HC 2.5% 30,4308076,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUCCINYLCHOLINE 20MG/ML10,4308078,CDM,636,RC,J0330,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUTEROL 5MG ML 0 5ML,4308083,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYALURONATE SOD 14MG/0.55ML SYRINGE,4308093,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMATINIB 400MG TAB,4308096,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 1000MG. INJECT,4308099,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARIPIPRAZOLE 10MG,4308102,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINIDINE GLUC 324MG SA,4308104,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINIDINE GLUC 10ML VIAL,4308112,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RABIES VAC.HUMAN DIP 2.5U,4308121,CDM,636,RC,90675,HCPCS,Outpatient,,,0.01,0.01,,1163.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,328.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,591.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1149.92,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,755.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,328.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1163.06,
QUININE SULFATE 324 MG CAPSULE,4308122,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MILRINONE 5MG / 5ML INJ,4308137,CDM,636,RC,J2260,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENTOLAMINE 5MG INJ VL,4308140,CDM,636,RC,J2760,HCPCS,Outpatient,,,0.01,0.01,,1605.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,453.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,816.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1587.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1605.95,
METRONIDAZOLE 1% GEL 60GM,4308141,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MINOCYCLINE 50MG CAP,4308147,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 5% RECTAL CREAM 30GM,4308148,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 5% RECTAL CREAM 15GM,4308149,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOCLOPRAMIDE 10MG U/D,4308150,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOCLOPRAMIDE 5MG TAB,4308151,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOCLOPRAMIDE 10MG/10ML,4308152,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOCLOPRAMIDE 10MG/2ML,4308156,CDM,636,RC,J2765,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOBUTAMINE BAG 250 MG/250 ML IV,4308172,CDM,636,RC,J1250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ICAR 15MG CHEW TABLET,4308176,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MONTELUKAST 4MG CHEW TAB,4308179,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMAZEPAM 15MG CAP U/D,4308186,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMAZEPAM 30MG CAP U/D,4308188,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIFAMPIN 300MG CAP,4308208,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIMETHYL SULFOXIDE 50ML,4308210,CDM,636,RC,J1212,HCPCS,Outpatient,,,0.01,0.01,,2413.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,681.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1227.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2386.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1568,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,2413.35,
PNEUMOCOCCAL CONJ -20 VACCINE (MOSS),4308225,CDM,636,RC,90677,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPHENIDATE 5MG TAB,4308234,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPHENIDATE 10MG,4308240,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXAMETHASONE 0.2MG/ML NSY INJ,4308242,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOCARBAMOL 100MG/ML 10ML,4308252,CDM,636,RC,J2800,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHCARBAMOL 500MG TAB UD,4308254,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHOCARBAMOL 750MG,4308256,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYCOPYRROLATE 1MG TAB,4308264,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLYCOPYRROLATE .2MG/ML VL,4308268,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFENESIN-COD PHOS 5ML,4308277,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFENESIN 100MG/5ML UD,4308281,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
KETOCONAZOLE SHAMPOO,4308283,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFEN/DM SYRUP 5ML,4308295,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFAZOLIN 20MG/MLPB16.7ML,4308300,CDM,636,RC,J0690,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFEN/PSEUDOEPHED 5MLSY,4308301,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROCALTROL .25MCG CAPSULE,4308306,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFTRIAXONE PER 250MG INJ,4308309,CDM,636,RC,J0696,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERFLUTREN LIPID MICROSHERE 1.1MG/ML,4308315,CDM,636,RC,Q9957,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLINDAMYCIN VAGINAL CREAM,4308316,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUVASTATIN 20 MG CAP,4308317,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OLANZAPINE 10MG INJ,4308324,CDM,636,RC,J2358,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRANEXAMIC ACID 1000MG/10ML INJ,4308325,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRANEXAMIC 650 MG TABLET,4308326,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFEN/D-METH/P-EPHRINE 5ML LIQ,4308335,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEG TUBE BOX,4308337,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INSULIN ISOPHANE NPH 1 UN,4308341,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN NPL/LISPRO 75/25,4308342,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LURASIDONE 20 MG TAB,4308346,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 400MG TAB U/D,4308349,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 600MG TAB U/D,4308351,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZACITIDINE 1MG (100MG) INJ,4308352,CDM,636,RC,J9025,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MOMETASONE 220MCG 30INHL,4308362,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SCOPOLAMINE 0.4MG/ML VIAL,4308388,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TERCONAZOLE 45GM VAG CRM,4308399,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACEBUTOLOL 200MG CAP,4308402,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SELENIUM 50MCG TABLET,4308405,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SELENIUM 2.5% LOTION 4OZ,4308406,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRILAT 2 5MG 2ML VL,4308411,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRILAT 1.25MG INJ (1ML),4308412,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LURBINECTEDIN 0.1 MG INJ (4 MG),4308413,CDM,636,RC,J9223,HCPCS,Outpatient,,,0.01,0.01,,696.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,196.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,354.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,688.87,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,452.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,696.74,
SENNA/DOCUSATE TAB,4308422,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SENNA TABLET U/D,4308424,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFAME/TRIMET 10ML SUSP,4308425,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFADIAZINE 500MG TAB,4308431,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFAM/TRIM 800-160MG TAB,4308432,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFDINIR 125MG/5ML 60ML,4308435,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFA/TRIM 400-80MG TAB U,4308440,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SULFAMETHOXAZOLE-TRIMETHOPRIM 5ML VIAL,4308441,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RESLIZUMAB 1MG INJ FD,4308449,CDM,636,RC,J2786,HCPCS,Outpatient,,,0.01,0.01,,36.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,18.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.04,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,36.46,
RESLIZUMAB 1MG INJ (100MG VIAL),4308450,CDM,636,RC,J2786,HCPCS,Outpatient,,,0.01,0.01,,36.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,18.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.04,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,36.46,
ETANERCEPT 25MG INJ,4308451,CDM,636,RC,J1438,HCPCS,Outpatient,,,0.01,0.01,,2799.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,790.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1423.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2767.73,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1818.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,790.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,2799.36,
ORITAVANCIN 400MG VIAL,4308452,CDM,636,RC,J2407,HCPCS,Outpatient,,,0.01,0.01,,97.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,49.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.39,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,63.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,27.54,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,97.49,
OXAZEPAM 10MG CAP U/D,4308456,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXAZEPAM 15MG CAP U/D,4308458,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXAZEPAM 30MG CAP U/D,4308460,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARUNAVIR 800MG TAB,4308468,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZTREONAM 1GM VIAL,4308469,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZTREONAM 20MG/ML PEDI,4308470,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILVER SULFAD 1% 50GM CR,4308496,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILVER SULFAD 1% 400GM CR,4308498,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILVER NITRATE APPLICA EA,4308500,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBOXYME-CELLULOSE 1%OPT,4308501,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE/MINERAL OIL/PETROLATU 57GM,4308502,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBIDOPA/LEVODOPA 10/100,4308506,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBIDOPA/LEVO 25/100 UD,4308510,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBIDOPA/LEVO 25/250 UD,4308514,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 3MG TABLET,4308526,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXEPIN  10MG CAPSULE UD,4308530,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXEPIN  25MG CAPSULE UD,4308532,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXEPIN  50MG CAPSULE UD,4308534,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 5MG ML 25ML,4308549,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE ER 300MG CAP,4308552,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE SR 450MG TAB,4308555,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE ER 100MG CAP,4308556,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCTREOTIDE 50MCG/ML,4308557,CDM,636,RC,J2354,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCTREOTIDE 500MCG/ML,4308558,CDM,636,RC,J2354,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALACYCLOVIR 500 MG CAP,4308559,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 100MCG/HR PATCH,4308563,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 75MCG/HR PATCH,4308565,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TALC STERILE 5GM,4308566,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 50MCG/HR PATCH,4308567,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE DINIT./HYDRALAZINE 20/37.5MG,4308568,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 25MCG/HR PATCH,4308569,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE NURSERY 25MCG/ML SUSP,4308574,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CEFDINIR 300MG CAPSULE,4308576,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RITONAVIR 100MG TAB,4308578,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DALBAVANCIN 5MG INJ (500 MG),4308579,CDM,636,RC,J0875,HCPCS,Outpatient,,,0.01,0.01,,53.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,27.37,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.23,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,34.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,15.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,53.84,
IRINOTECAN LIPOSOMAL 1MG INJ (43mg/10ml),4308580,CDM,636,RC,J9205,HCPCS,Outpatient,,,0.01,0.01,,221.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,62.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,112.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,143.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,221.21,
PSYLLIUM 862 GM,4308581,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POTASS CL 8MEQ SA TAB U/D,4308596,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM ACETATE 20ML VIAL,4308598,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARB 650MG TAB,4308602,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARB 5MEQ 10ML S,4308604,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARB10MEQ 10ML S,4308606,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARBONATE 8.4% 10ML VIAL,4308607,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM BICARB 50MEQ 50ML S,4308608,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL 50MEQ 20ML VIAL,4308612,CDM,250,RC,J7131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL 23 4  30ML VIAL,4308614,CDM,250,RC,J7131,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL 1GM TABLET EC,4308616,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL BACT .9% 30ML,4308622,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CHLOROTHIAZIDE 500MG INJ,4308624,CDM,636,RC,J1205,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD CHL RESP THER 3ML,4308625,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM PHOSPHATE 3 MMOLE/ML (5ML),4308632,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYCLOPHOSPHAMIDE 25MG CAPSULE,4308633,CDM,636,RC,J8530,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD THIOSULFATE 25% 50ML VIAL,4308635,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM PHOSPHATE 15ML VL,4308636,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Nasal flu vaccine,4308639,CDM,636,RC,90672,HCPCS,Outpatient,,,0.01,0.01,,98.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.27,350,,,Fee Schedule,350% of CMS OPPS Rate,28.35,102,,,Fee Schedule,102% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,230,,,Fee Schedule,230% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,27.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.38,
SULFACETAMIDE 10% OPH15ML,4308642,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEONATAL RESUSCITATION KIT,4308649,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
NEONATAL RESUSCITATION KIT USED,4308650,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
VARENICLINE 1MG TAB,4308657,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMETREXED 100MG VIAL,4308671,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
NORGEST/ETHINYL ESTRADIOL .5MG/50MCG TAB,4308704,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN NPH/REG 70/30 1UN,4308715,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUTORPHANOL 1MG/ML 1ML,4308721,CDM,636,RC,J0595,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUTORPHANOL 2MG/ML 1ML,4308722,CDM,636,RC,J0595,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RABIES IMMUNE GLOBUL 150U/ML 10ML,4308723,CDM,636,RC,90375,HCPCS,Outpatient,,,0.01,0.01,,983.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,277.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,499.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,972.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,638.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,983.19,
RITUXIMAB 10 MG AND HYALUR INJ (1600MG),4308724,CDM,636,RC,J9311,HCPCS,Outpatient,,,0.01,0.01,,131.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,37.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,66.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.94,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,131.44,
RITUXIMAB 10 MG AND HYALUR INJ (1400MG),4308725,CDM,636,RC,J9311,HCPCS,Outpatient,,,0.01,0.01,,131.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,37.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,66.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.94,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,85.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,37.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,131.44,
AMIKACIN 5 MG/ML PEDI,4308726,CDM,636,RC,J0278,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CISPLATIN 10MG INJ (200MG),4308739,CDM,636,RC,J9060,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOCAINE-MENTHOL 20-0.5% TOP 3 OZ,4308740,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUDES/FORM 80/4.5 INH,4308744,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SILDENAFIL 10 MG/ 12.5 ML INJ,4308747,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIFLUOPERAZINE 2MG TAB,4308752,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIFLUOPERAZINE 5MG TAB,4308754,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIFLUOPERAZINE 10MG TAB,4308756,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
QUINAPRIL 40MG TABLET,4308758,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 2MG/MLPB100ML,4308760,CDM,636,RC,J1450,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CILOSTAZOL 100MG TAB UD,4308761,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYTOIN SODIUM EXTENDED 30MG CAP,4308763,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STREPTOMYCIN 1GM  VIAL,4308770,CDM,636,RC,J3000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"MULTIVITAMINS, STRESSFORM",4308782,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD POLYSTYRENE SUSP 60ML,4308787,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRENATAL VITAMIN FA=1MG,4308790,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL PCA 300CG/ 30ML,4308791,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL .05MG/ML AMP 2ML,4308792,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL 0.05 MG/ML 50 ML VIAL,4308793,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% MPF 10ML AMP,4308795,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL .05MG/ML AMP20ML,4308796,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENTANYL .05MG/ML AMP 5ML,4308798,CDM,636,RC,J3010,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACCESS REFRIGERATOR - LIDOCAINE START,4308802,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
DABIGATRAN ETEXILATE MES. 75 MG,4308805,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DABIGATRAN ETEXILATE MES. 150 MG,4308806,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PSEUDOEPHEDRINE 120MG SA,4308812,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUFENTA 1ML AMP INJ,4308814,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUFENTA 2ML AMP INJ,4308815,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SUFENTA 5ML AMPUL INJ,4308816,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRALATREXATE 1 MG (20MG/ML) VIAL,4308818,CDM,636,RC,J9307,HCPCS,Outpatient,,,0.01,0.01,,1055.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,298.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,536.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1043.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,685.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1055.55,
PEDI MULTIVITAMIN #40-PHYTONADIONE 60ML,4308827,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXOCOBALAMIN 1000MCG/ML,4308830,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HOME MEDICATIONS STORED IN PHARMACY,4308841,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
DOCUSATE CALCIUM 240MG UD,4308844,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIODARONE 450MG/9ML INJ,4308845,CDM,636,RC,J0282,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMIODARONE 360 MG/200ML PREMIXED,4308846,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DROXIDOPA 100 MG CAP,4308850,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESMOLOL HCL 10MG ML 10ML,4308859,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRETYLIUM 500MG 10ML VIAL,4308861,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEFEROXAMINE 500MG VIAL,4308863,CDM,636,RC,J0895,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMANTADINE 100MG/10ML SYR,4308874,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMANTADINE 100MG CAP U/D,4308875,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
APIXABAN 2.5 MG TAB,4308876,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
APIXABAN 5 MG TAB,4308877,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EDOXABAN 60 MG TABLET,4308878,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINOLONE 0.025% CREAM 15GM,4308879,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINOLONE .05% CRE 30,4308884,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CYTARABINE 200MG/ 20ML VIAL,4308889,CDM,636,RC,J9100,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAMIDRONATE 3MG/ML 10ML,4308892,CDM,636,RC,J2430,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PAMIDRONATE 9MG/ML 10ML,4308893,CDM,636,RC,J2430,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM 25MG/5ML VIAL,4308894,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIZEM 50MG/10ML INJ.,4308895,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIMPLE SYRUP 30ML,4308896,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DILTIAZEM ER 240MG UD CAP,4308897,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 0.3% 2.5ML,4308899,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIPROFLOXACIN 0.3% OPTH 5ML,4308900,CDM,636,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEMABATE 250MCG/ML INJ,4308903,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOTENSIN 10MG UD TABLET,4308907,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE 200MCG,4308913,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE .05MG U/D,4308915,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE 100MCG INJ,4308916,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE 0.1MG TAB,4308917,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE 0.15MG TAB,4308918,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVOTHYROXINE .2MG TAB,4308919,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VOLTAREN OPHT 0.1% 5ML,4308922,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RABIES IMMUNE GLOBUL 150U/ML 2ML,4308924,CDM,636,RC,90375,HCPCS,Outpatient,,,0.01,0.01,,983.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,277.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,499.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,972.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,638.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,277.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,983.19,
TICLOPIDINE 250MG TAB,4308926,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIGECYCLINE 50MG VIAL,4308934,CDM,636,RC,J3243,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIMETADINE 400MG TAB,4308940,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIMETADINE 300MG 2ML VL,4308942,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CIMETADINE 300MG TAB,4308946,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENICILLIN G 2.5MU/100ML PB,4308947,CDM,636,RC,J2540,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENICLLIN G POTASSIUM 5 MU IN NS PB,4308948,CDM,636,RC,J2540,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTAZOCINE/APAP 25/650 T,4308956,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTAZOCINE/NALOXONE TAB,4308964,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLECAINIDE 100MG TAB,4308966,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLECAINIDE 50MG TAB,4308968,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHIMAZOLE 10MG TAB,4308972,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZOCAINE 20% UD SPRAY,4308985,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEARS NATURALE 15ML DROPS,4308994,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLARITHROMYCIN 250MG/5ML 50ML,4308996,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAMIVUDINE 150MG TAB,4308997,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LAMIVUDINE 50MG/5ML ORAL,4308998,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DINOPROSTONE 10MG INSERT,4308999,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUVOXAMINE 100MG TAB UD,4309001,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM HYALURONATE (PROVISC 0.55ML) INJ,4309002,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPYRIDAMOLE/ASA 200/25MG,4309007,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FENOFIBRATE 48MG TAB,4309009,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INDAPAMIDE 1.25MG TABLET,4309011,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMINOPHYL ORAL 105MG/5ML,4309015,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCHLOROTHIAZIDE 5MG/ML SUSP,4309017,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBAMAZEPINE 100MG CHEW,4309020,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESONIDE 0.05% CREAM 15GM,4309021,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARBAMAZEPINE 200MG TABUD,4309024,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIACIN SA 500MG,4309026,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOX K/CLAV XR 1000MG,4309031,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATOMOXETINE 25MG CAP,4309033,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATOMOXETINE 60MG CAP,4309036,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GATIFLOXACIN 0.5% OPTH. DROP,4309038,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATENOLOL 50MG TABLET UD,4309040,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATENOLOL 100MG TABLET UD,4309042,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUANFACINE 1MG TAB,4309043,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMCICLOVIR 125MG TAB,4309044,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIVALPROEX ER 250MG,4309045,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTOBARBITAL SOD 50MG/ML 20ML,4309047,CDM,636,RC,J2515,HCPCS,Outpatient,,,0.01,0.01,,120.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,34.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,61.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,119.35,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,78.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,34.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,120.71,
MOXIFLOXACIN 400MG,4309048,CDM,636,RC,J2280,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACYCLOVIR 5MG/ML 16.7MLPB,4309050,CDM,636,RC,J0133,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEPOLIZUMAB 100MG VIAL,4309051,CDM,636,RC,J2182,HCPCS,Outpatient,,,0.01,0.01,,106.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.59,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,69.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,106.8,
ESTROGENS CONJ 1.25MG SYNTHETIC,4309052,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERAPAMIL PM 100MG,4309053,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RIVASTIGMINE 13.3 MG/24 HOUR PATCH,4309054,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL BACTERIOSTATIC 0.9% 10ML,4309055,CDM,250,RC,A4216,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
meningococcal Meningococcal conjugate vaccine,4309056,CDM,636,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
meningococcal Meningococcal conjugate vaccine,4309058,CDM,636,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
meningococcal Meningococcal conjugate vaccine,4309059,CDM,636,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLDOPA/HCTZ 250-15MG,4309060,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MELATONIN 3MG TAB,4309061,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MELOXICAM 7.5MG TAB,4309063,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACYCLOVIR 5% OINT 5GM,4309065,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MENINGOCOCCAL SEROB VACCINE BEXSERO,4309067,CDM,636,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IODINE STRONG 5% 8ML,4309069,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM CL BACTERIOSTATIC 0.9% 20ML,4309070,CDM,250,RC,A4216,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE PCA 30MG/30ML CSP,4309071,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOD HYALURONATE 14MG/ML INJ(0.85ML SYR),4309072,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPHENHYDRAMINE 50MG/ML (10ML) INJ,4309074,CDM,636,RC,J1200,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENZONATATE 100MG CAP,4309076,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TD ADULT,4309078,CDM,636,RC,90714,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETRACAINE 0.5% 4ML OPHTH SOLN,4309082,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETRACAINE .5% 2ML UD,4309084,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETRACAINE 0.5% 0.6ML VISC,4309087,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ITRACONAZOLE 100MG/10ML SOLN,4309088,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINONIDE 0.05% 60GM O,4309089,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEGESTROL 400MG 10ML,4309090,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEGESTROL ES 125MG/ML 5ML SUSP,4309091,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE SR 100MG TAB,4309095,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE SR 200MG TAB,4309096,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE SR 300MG TAB,4309097,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOCINONIDE 0.05% OINT 15GM,4309100,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ARFORMOTEROL INH 15MCG,4309113,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYALURONIDASE 150U/ML 1ML,4309118,CDM,636,RC,J3470,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLTERODINE LA 4MG CAP,4309124,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLTERODINE LA 2MG,4309125,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROPRUSSIDE 20MG/100ML NS INJ,4309132,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE 80MG/15ML ORAL SOLN,4309136,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIAMINE 50MG TABLET UD,4309156,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THIAMINE 100MG TABLET UD,4309158,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2  AMP 2ML,4309175,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEMANTINE 5MG TAB,4309203,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRAVOPROST 0.004% 2.5ML,4309204,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPHETAMINE MIXTURE ER 5MG,4309205,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GLIMEPIRIDE 1MG TAB,4309207,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLTERODINE 1MG TAB,4309208,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CABOTEG-RILPIV 2-3MG INJ (400/ 600MG) FD,4309211,CDM,636,RC,J0741,HCPCS,Outpatient,,,0.01,0.01,,78.9,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,22.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,40.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,51.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,22.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,78.9,
RISPERIDONE CONSTA 25MG,4309212,CDM,636,RC,J2794,HCPCS,Outpatient,,,0.01,0.01,,43.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,21.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.52,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,43.01,
THYROID 32MG TABLET UD,4309213,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THYROID 65MG TABLET UD,4309214,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SIROLIMUS 1MG TAB,4309215,CDM,636,RC,J7520,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESOMEPRAZOLE 40MG CAP UD,4309217,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RISPERIDONE CONSTA 37.5MG,4309219,CDM,636,RC,J2794,HCPCS,Outpatient,,,0.01,0.01,,43.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,21.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.52,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,43.01,
RISPERIDONE CONSTA 50MG,4309223,CDM,636,RC,J2794,HCPCS,Outpatient,,,0.01,0.01,,43.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,21.87,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.52,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,43.01,
ESCITALOPRAM 20MG TAB UD,4309234,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TACROLIMUS 0.5MG CAP,4309235,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOPROLOL XL 100MG,4309236,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ESOMEPRAZOLE 20MG CAP UD,4309237,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRIMETHOBENZAMIDE 200MG/2,4309238,CDM,636,RC,J3250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROSUVASTATIN 10MG TAB,4309246,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXTROMETHORPH/QUINIDINE 20/10 CAP,4309247,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIMOLOL OPH .5% 5ML,4309250,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TIMOLOL OPH .25% 5ML,4309251,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESLORATADINE 5MG TAB,4309254,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESMOPRES ACE 0.1MG/ML NS,4309256,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLNAFTATE 1% POWDER SPRAY,4309257,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOLNAFTATE 1% 15GM CREAM,4309258,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALFUZOSIN 10MG TAB,4309260,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN .3% OPH 5ML,4309272,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN .3% 3.5GM OINT,4309274,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPRAMINE 10MG TABLET,4309277,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPRAMINE 25MG TAB U/D,4309278,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPRAMINE 50MG TAB U/D,4309279,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IMIPRAMINE PAM 100MG SA,4309283,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BELTATACEPT 250MG VIAL,4309284,CDM,636,RC,J0485,HCPCS,Outpatient,,,0.01,0.01,,13.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,6.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.26,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,8.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,13.41,
RISEDRONATE 35MG TABLET,4309307,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PULSE OXY,4309308,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
HAEMOPH B POLY CONJ-MENG,4309309,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESOXIMETASONE .25% CR 15,4309310,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIMECROLIMUS 1% 30GM,4309313,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESOXIMETASONE 0.05% GEL15 GM,4309314,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESOXIMETASONE .25%OINT15,4309318,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BUPROPION XL 150MG,4309319,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SERTRALINE 100MG,4309321,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SERTRALINE 25MG TABLET,4309322,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BALSALAZIDE 750MG CAP,4309327,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSULFAN BLUE 1  5ML,4309330,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"ELECTROLYTES, TPN 20ML VL",4309332,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZINC OXIDE 40% OINT,4309333,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRACE METAL 5ML VIAL INJ,4309334,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRACE-4 ELEMENTS ADULT INJ (1ML),4309337,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OSELTAMIVIR 6MG/ML 60ML ORAL SUSP,4309341,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NTG 10MG PATCH,4309346,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SCOPOLAMINE PATCH 1.5MG 1,4309354,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VALGANCICLOVIR 450MG TAB,4309355,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLORAZEPATE 3.75MG TAB,4309362,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLORAZEPATE 7.5MG TAB,4309364,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENTOXIFYLLINE 400MG SA T,4309371,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GUAIFENESIN DM 600/30MG T,4309373,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EFAVIRENZ 200MG CAP,4309406,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCODONE/APAP 10/325,4309407,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESOXIMETAS 0.25% 60GM OINT,4309418,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DESONIDE .05% 15GM OINT,4309423,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NITROGLYCERIN 5MG/ML 10ML,4309429,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRILAFON 2MG TABLET,4309439,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STARCH SUPPOSITORY,4309440,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PERPHENAZINE 4MG TAB,4309441,CDM,636,RC,Q0175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN 125MG/5ML 100,4309453,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN 250MG/5ML 80ML SUSP,4309456,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN 250MG/5ML 100,4309458,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN 250MG CAP U/D,4309459,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN/CLAVULATE 400,4309460,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TEMOZOLOMIDE 5MG CAPSULE,4309461,CDM,636,RC,J8700,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMOXICILLIN 500MG CAP U/D,4309462,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 3.5MG TABLET,4309466,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TRICON CAPSULE,4309473,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MEDROXYPROGESTERONE 150MG**PNT OWN MED**,4309492,CDM,636,RC,J1050,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEMAMELIS/BENZALKON PADS,4309494,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LITHIUM CITRATE 300MG/5ML,4309501,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CALCIUM CARB500MG CHEW TA,4309502,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOBRAMYCIN FOR NEB 300MG,4309511,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GADOLINIUM 287MG/ML,4309515,CDM,636,RC,A9579,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPARIN FLUSH 3U/3ML,4309525,CDM,636,RC,J1642,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCOD/CHLOR POL 5ML SU,4309540,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GENVOYA 150MG-150MG-200MG-10MG TAB,4309541,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIVOLUMAB 1MG INJ 4ML FD,4309542,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
TELMISARTAN 20MG TAB,4309543,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NIVOLUMAB 1MG INJ 24 ML FD,4309544,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
NIVOLUMAB 1MG INJ 10 ML FD,4309545,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
CHLORPROMAZINE 100MG TAB,4309546,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SYSTANE GEL EYE DROPS 10ML,4309548,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPILIMUMAB 1 MG INJ 10 ML FD,4309549,CDM,636,RC,J9228,HCPCS,Outpatient,,,0.01,0.01,,596.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,303.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,387.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,596.7,
IPILIMUMAB 1 MG INJ 40 ML FD,4309550,CDM,636,RC,J9228,HCPCS,Outpatient,,,0.01,0.01,,596.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,303.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,387.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,596.7,
ACETAMINOPH 80MG TAB CHEW,4309551,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN DROPS 15ML,4309552,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VENLAFAXINE 25MG TAB,4309554,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETAMINOPHEN  325MG,4309555,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHADONE SOL 1MG/ML,4309556,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETOMINOPHEN W/COD #3 TA,4309561,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEHYDRATED ALCOHOL 5ML,4309562,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOSORBIDE MONONI.SR 60MG,4309565,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIPERAC/TAZOBAC 3.375 GM PB,4309571,CDM,636,RC,J2543,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PIPERAC/TAZOBAC A-V 3.375 GM VIAL,4309572,CDM,636,RC,J2543,HCPCS,Outpatient,,,170,102,,30.6,18,,,percent of total billed charges,pays at 18% of total charges,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,50,,,percent of total billed charges,pays at 50% of total billed charges,119,70,,,percent of total billed charges,70% of total billed charges,127.5,75,,,percent of total billed charges,75% of total billed charges,85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,170,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.64,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.64,170,
PIPERACILLIN/TAZ 3.375 GM VIAL,4309573,CDM,636,RC,J2543,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EDETATE DISODIUM 2% OPHTHALMIC,4309581,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM GLUCONATE 500MG,4309583,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAFCILLIN 2GM INJ,4309594,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAFCILLIN 1GM INJ,4309595,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VENLAFAXINE 37.5MG TABLET,4309601,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
THEOPHYLLINE 400MG CR TAB,4309602,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICILLIN/SULBACT 1.5GM,4309603,CDM,636,RC,J0295,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROMORPHONE 10MG/ML,4309604,CDM,636,RC,J1170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EDETATE DISOD 150MG/ML 20ML,4309605,CDM,636,RC,J3520,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EDETATE CAL DISODIUM 200MG/ML 2.5ML,4309606,CDM,636,RC,J0600,HCPCS,Outpatient,,,0.01,0.01,,20208.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,5708.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,10275.45,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19980.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,13129.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5708.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,20208.4,
ZIDOVUDINE 100MG CAPSULE,4309607,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CANDESARTAN 32MG TAB,4309610,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMPICLLIN/SULBACTAM 3GM,4309613,CDM,636,RC,J0295,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHENAMINE 1GM TAB,4309614,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METH/M BLUE/SALOL/HYOS TA,4309616,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOPOTECAN 0.1MG INJ (4MG VIAL),4309617,CDM,636,RC,J9351,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLAVOXATE 100MG TAB,4309621,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POT CITRATE 540MG SA TAB,4309623,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CANAGLIFLOZIN 100MG TABLET,4309626,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CANAGLIFLOZIN 300MG TABLET,4309627,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUCONAZOLE 10MG/ML 35ML,4309632,CDM,636,RC,J1450,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
COAGULATION FACTOR Vlla1 mcg inj (5mg),4309636,CDM,636,RC,J7189,HCPCS,Outpatient,,,0.01,0.01,,8.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.52,
COAGULATION FACTOR Vlla 1 mcg inj (2mg),4309637,CDM,636,RC,J7189,HCPCS,Outpatient,,,0.01,0.01,,8.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.52,
COAGULATION  FACTOR Vlla 1 mcg inj (1mg),4309638,CDM,636,RC,J7189,HCPCS,Outpatient,,,0.01,0.01,,8.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.52,
"VIT A PAM 100,000U/2ML",4309654,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETHAMET DIPR.05% 60ML LOT,4309662,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIPYRIDAMOLE 25MG UD,4309663,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BETAMETHASONE .01% CR 15GM,4309666,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMLODIPINE 2.5MG TAB,4309667,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 5MG/ML 10ML INJECTION,4309668,CDM,636,RC,J3360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 10MG/2ML CPUJCT,4309669,CDM,636,RC,J3360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 10MG/2ML INJECTION CSP,4309670,CDM,636,RC,J3360,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POVID-IODIN 10% SOLN 118ML,4309672,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 2MG TAB UD,4309673,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 5MG TAB UD,4309674,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DIAZEPAM 10MG TAB UD,4309675,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCORTISONE 2.5% OINT 30GM,4309676,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DUOVISC 0.55ML,4309685,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NISOLDIPINE 8.5MG TAB,4309687,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 500MG INJ VL,4309688,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 250MG/5ML SOLN 40ML,4309689,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN 50MG OPHTHALMIC SOLN,4309690,CDM,636,RC,J3370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN ORAL SOLN 25MG/ML 5ML,4309691,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VANCOMYCIN LOCK CATHETER SOLN 5MG/ML,4309692,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BRIMONIDINE/TIMOLOL OPTH,4309701,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NAPHCON FORTE 0.1% OPH 15,4309702,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METHYLPHENIDATE ER 27MG,4309705,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEXMEDETOMIDINE 200MCG/2ML INJ,4309706,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHENYLEPHRINE 2.5% 10ML OPHTH,4309707,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRIL 5MG TAB U/D,4309713,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRIL 10MG TAB U/D,4309714,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENALAPRIL 20MG TAB,4309715,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RASBURICASE 1.5MG,4309719,CDM,636,RC,J2783,HCPCS,Outpatient,,,0.01,0.01,,1268.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,358.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,645.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1254.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,824.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,358.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1268.83,
PENICILLIN V POT 250/MG/5ML SUSP (100ML),4309720,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AFLIBERCEPT 1MG (2MG INJ),4309721,CDM,636,RC,J0178,HCPCS,Outpatient,,,0.01,0.01,,3073.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,868.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1562.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3038.84,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1996.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3073.56,
PENICILLIN 250MG TAB,4309723,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENICILLIN 500MG TAB,4309725,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INSULIN REGULAR 125 UNITS/500ML IV DRIP,4309726,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 100MG/5ML (10ML) SUSP,4309727,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOCETAXEL 1MG INJ (80MG/8ML),4309729,CDM,636,RC,J9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IBUPROFEN 100MG/5ML DYE-FREE SUSP,4309730,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VINORELBINE 10MG (50MG) INJ,4309732,CDM,636,RC,J9390,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RAVULIZUMAB-CWVZ 10MG INJ 11 ML,4309742,CDM,636,RC,J1303,HCPCS,Outpatient,,,0.01,0.01,,784.71,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,221.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,399,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,775.84,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,509.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,221.67,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,784.71,
ALBUTEROL SOLN 0.5% 20ML,4309753,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LOSARTAN 50MG TABLET,4309754,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACTIVATED CHARCOAL 50GM/240ML,4309755,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BISOPROLOL 5MG TABLET,4309756,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANAFRANIL 25MG TABLET,4309760,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 5MG/ML 2ML VIAL,4309763,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIDAZOLAM 5MG/ML 5ML VIAL,4309766,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEGFILGRASTIM DELIV KIT 0.5MG (6MG/0.6ML,4309767,CDM,636,RC,J2506,HCPCS,Outpatient,,,0.01,0.01,,265.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,74.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,134.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,262.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,172.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,74.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,265.32,
MIDAZOLAM 5MG/ML 1ML VIAL,4309769,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
STERILE WATER 100 ML INJ,4309779,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEPATITIS B IMMUNE GLOBULIN INJ 5ML,4309780,CDM,636,RC,90371,HCPCS,Outpatient,,,0.01,0.01,,487.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,247.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.53,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,316.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,487.03,
ABATACEPT 10MG INJ FD,4309782,CDM,636,RC,J0129,HCPCS,Outpatient,,,0.01,0.01,,151.15,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,76.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,149.44,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,42.7,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,151.15,
PALIPERIDONE PALIMATE 1MG (234MG) INJ FD,4309783,CDM,636,RC,J2426,HCPCS,Outpatient,,,0.01,0.01,,50.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,32.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,50.76,
AGALSIDASE BETA 1MG (35MG) INJ FD,4309784,CDM,636,RC,J0180,HCPCS,Outpatient,,,0.01,0.01,,770.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,391.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,761.6,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,500.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,770.3,
PHENYLEPHRINE 100MCG/ML 10ML SYR,4309785,CDM,636,RC,J2370,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALBUTEROL HFA 90 MCG INH 8.5 GM,4309786,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OXYTOCIN 10 UNITS/ML 10ML INJ,4309787,CDM,636,RC,J2590,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IPRAT/ALB 4 GM INH,4309788,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MAGNESIUM SULFATE 500MG//ML 20ML INJ,4309791,CDM,636,RC,J3475,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MICONAZOLE 2% POWDER 85GM,4309792,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LUSPATERCEPT-AAMT 0.25MG INJ (75 MG),4309793,CDM,636,RC,J0896,HCPCS,Outpatient,,,0.01,0.01,,138.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.22,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,90.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.8,
MEPERIDINE 100MG INJ 2ML,4309794,CDM,636,RC,J2175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"BUPVAC-EPI 0.5% 1:200,000 50ML INJ",4309795,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LUSPATERCEPT-AAMT 0.25MG INJ (25 MG),4309796,CDM,636,RC,J0896,HCPCS,Outpatient,,,0.01,0.01,,138.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.22,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,90.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.8,
PERTUZ-TRASTUZ-HYAL 10MG  (600MG),4309797,CDM,636,RC,J9316,HCPCS,Outpatient,,,0.01,0.01,,240.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,67.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,122.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.68,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,156.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,240.4,
VITAMIN B 12 500 MCG TAB,4309800,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CRIZANLIZUMAB-TMCA 5 MG INJ (100),4309801,CDM,636,RC,J0791,HCPCS,Outpatient,,,0.01,0.01,,449.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,126.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,228.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,449.08,
BAMLANIVIMAB 700 MG INJ **PT ASSISTANCE*,4309802,CDM,636,RC,Q0239,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMETREXED 10MG INJ (100 MG) FD,4309804,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
PEMETREXED 10MG INJ (500 MG) FD,4309805,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
CARBOPLATIN 50 MG INJ (450 MG) FD,4309806,CDM,636,RC,J9045,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SOTALOL HCL 80MG TABLET,4309807,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCODONE/APAP 5/500 TA,4309808,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROCODONE/APAP 5/325MG TAB,4309809,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
EPLERENONE 50 MG TABLET,4309810,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
40% GLUCOSE ORAL GEL 3ML,4309815,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SODIUM ZIRCONIUM 10GM SUSP,4309819,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAMOTIDINE 8 MG/ML SUSP (30 ML),4309821,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ATEZOLIZUMAB 10MG INJ (20 ML) FD,4309822,CDM,636,RC,J9022,HCPCS,Outpatient,,,0.01,0.01,,292.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,148.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,289.17,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,190.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,82.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,292.47,
ZOLEDRONIC ACID 1MG (4MG) INJ FD,4309823,CDM,636,RC,J3489,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOCILIZUMAB 1 MG INJ (400 MG) VIAL) FD,4309824,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
IVABRADINE 5 MG TAB,4309826,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
REVEFENACIN 1 MCG INHL 175 MCG,4309827,CDM,636,RC,J7677,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOCILIZUMAB 1 MG INJ (80MG VIAL) FD,4309828,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
TOCILIZUMAB 1 MG INJ (200 MG VIAL) FB,4309829,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
VEDOLIZUMAB 1 MG INJ (300 MG) FD,4309830,CDM,636,RC,J3380,HCPCS,Outpatient,,,0.01,0.01,,78.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,40.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,78.05,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,51.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,78.94,
OCUVITE,4309832,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUOROURACIL 500 MG INJ 100 ML VIAL,4309834,CDM,636,RC,J9190,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE SUSP 25MG/5ML,4309835,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEDIATRIC VITAMINS DROPS ACD 50ML,4309836,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE PALIMATE 1MG (156) INJ AJ,4309838,CDM,636,RC,J2426,HCPCS,Outpatient,,,0.01,0.01,,50.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,32.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,50.76,
DARBOPOETIN 1MCG INJ 60 MCG/0.3 ML,4309839,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
TRIFLURIDINE 1% 7.5ML,4309841,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DARBOPOETIN 1MCG INJ 60 MCG/0.3 ML ESRD,4309842,CDM,636,RC,J0882,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
TETRAHYDRAZOLINE.05% 15ML,4309843,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PALIPERIDONE PALIMATE 1MG (234) INJ AJ,4309844,CDM,636,RC,J2426,HCPCS,Outpatient,,,0.01,0.01,,50.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,32.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,50.76,
PINDOLOL 5MG TAB,4309845,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WARFARIN 1.25MG TAB,4309847,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HEP B IMM GLOB 220 UNITS/ML (1 ML),4309848,CDM,636,RC,90371,HCPCS,Outpatient,,,0.01,0.01,,487.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,247.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,481.53,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,316.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,137.58,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,487.03,
HYDROXYZINE PAM 25MG UD,4309852,CDM,636,RC,Q0177,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYDROXYZINE PAM 50MG UD,4309853,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN A&D 60GM OINTMENT,4309857,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ADENOCCARD 6MG/2ML,4309858,CDM,636,RC,J0153,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PHAZYME 125MG CAPSULE,4309859,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEVTHYROXINE 0.112MG,4309860,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON ODT 4MG TAB,4309862,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON ODT 8MG TAB,4309863,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN E 100IU CAPSULE,4309865,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MESTINON TIMESPAN 180MG,4309866,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN E 1000U CAPSULE,4309868,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN E 400IU CAP UD,4309869,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MIRTAZAPINE 15MG TAB,4309870,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUORESCEIN 10% 5ML INJECTION,4309871,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CETAPHIL CLEANSER,4309873,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN A/D OINTMENT 113 GM,4309881,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VITAMIN B COMPLEX 100,4309887,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETIC ACID/HYDRO 10MLGTT,4309888,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACETIC ACID 2% 15ML SOL,4309889,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
SELEGILINE 5MG,4309890,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARDENE 20 MG UD CAPSULE,4309891,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NEPHROCAPSETTE #1 EACH,4309892,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FLUTAMIDE 125MG CAP UD,4309895,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PREDNISOLONE ACETATE 1% OPTH DROP 1ML,4309898,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ACYCLOVIR 800MG  TABLET,4309899,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WATER FOR INJECTION 10ML,4309900,CDM,250,RC,A4216,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
WATER BACTERIOSTATIC 30ML,4309901,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
POLYTRIM OHTH SOLN,4309902,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUPROLIDE 3.75 MG (LUPRON 30MG-3MO) INJ,4309903,CDM,636,RC,J1950,HCPCS,Outpatient,,,0.01,0.01,,5396.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2743.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5335.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,3505.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,5396.16,
ROCURONIUM 100MG/10ML VIAL,4309905,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LEUCOVORIN  5MG TABLET,4309906,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
OCRELIZUMAB 300 MG/10 ML VIAL,4309908,CDM,636,RC,J2350,HCPCS,Outpatient,,,0.01,0.01,,214.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,60.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,108.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.92,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,139.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,214.34,
SOD CHLORIDE/SOD BICARB,4309910,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PRAVACHOL 10MG UD TABLET,4309912,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RELAFEN 500 MG UD TABLET,4309913,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERREX 150 FORTE,4309915,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MISOPROSTOL 100MCG TABLET,4309917,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
MORPHINE 15MG SA TABLET,4309918,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PENICILLIN G SODIUM 5 MMU VIAL,4309921,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% 10MG/ML 1ML,4309925,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARDIZEM CD 180MG CAP,4309928,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROCURONIUM 10MG/ML 5ML VL,4309932,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% 10MG/ML 1ML SYRINGE,4309933,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 5% 30GM OINT,4309937,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ISOPTO CARPINE 4% 15ML,4309939,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ANALPRAM HC 30GM CRM,4309940,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
HYTRIN 1MG UD TABLET,4309942,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CARDENE 30 MG UD CAPSULE,4309943,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALPRAZAPAM 0.25MG TAB,4309945,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALPRAZOLAM 0.5MG TAB,4309946,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALPRAZOLAM 1MG TAB,4309947,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 0 5  VIAL 50ML,4309948,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE W/EPI 1% 20ML V,4309949,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% 20MG/2ML AMP,4309950,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1  50MG 5ML AMP,4309952,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 4% 200MG/5ML AM,4309953,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% 200MG/10ML A,4309954,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% INJ 30ML AMP,4309955,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2% 5 ML JELLY,4309957,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE.5% 50ML VL REG,4309960,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 2  20ML VIAL,4309962,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE VISC 2% 15ML,4309963,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE VISC 2% 100ML,4309964,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% 100MG/10ML VIAL,4309965,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE TOPICAL 4% 50ML,4309966,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VERSED 2MG/2ML VIAL,4309967,CDM,636,RC,J2250,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE W/EPI 2% 20ML V,4309968,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAI W/EPI 2% 20ML MPF,4309969,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE W/EPI.5% 50ML V,4309970,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE W/GLU SPINAL 5%,4309971,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LIDOCAINE 1% 50ML VIAL,4309973,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOZARIL 25MG TABLET,4309975,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISINOPRIL 10MG TAB,4309978,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANITIDINE 75MG TABLET,4309979,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANITIDINE 150MG TAB U/D,4309981,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANITIDINE 25MG/ML 2ML VL,4309983,CDM,636,RC,J2780,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RANITIDINE (PEDI) IN NS 2MG/ML INJ,4309985,CDM,636,RC,J2780,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOZARIL 100MG  TABLET,4309986,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LISINOPRIL 5MG TABLET,4309987,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METOLAZONE 2.5MG TAB,4309989,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZAROXOLYN 5MG TABLET UD,4309990,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DEGARELIX 80MG INJ,4309992,CDM,636,RC,J9155,HCPCS,Outpatient,,,0.01,0.01,,14.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,7.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,9.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,14.62,
DEGARELIX 240MG INJ,4309993,CDM,636,RC,J9155,HCPCS,Outpatient,,,0.01,0.01,,14.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,7.43,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,9.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,14.62,
ZINC OXIDE 30GM OINTMENT,4309994,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ZINC SULFATE 220MG CAP UD,4309995,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
METFORMIN XR 500MG TAB,4309996,CDM,637,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ONDANSETRON HCL 4 MG VIAL,4309997,CDM,636,RC,J2405,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TETRACYCLINE 500MG IN NS 20ML SOLN,4309999,CDM,250,RC,,,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
URIC ACID SERUM,435550,CDM,301,RC,84550,HCPCS,Outpatient,,,124.65,74.79,,16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.52,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges,93.49,75,,,percent of total billed charges,75% of total billed charges,8.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,99.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.81,350,,,Fee Schedule,350% of CMS OPPS Rate,4.61,102,,,Fee Schedule,102% of CMS OPPS Rate,95.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,5.02,100,,,Fee Schedule,100% of UHC Fee Schedule,87.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,10.39,230,,,Fee Schedule,230% of CMS OPPS Rate,59.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.52,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,100,,,Fee Schedule,100% of CMS OPPS Rate,4.51,112.19,
CATHETER ASPIRATION,4360008,CDM,410,RC,31720,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,498,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,616.28,
HELIOX 80/20 PER HOUR,4360011,CDM,270,RC,,,Outpatient,,,80,48,,14.4,18,,,percent of total billed charges,pays at 18% of total charges,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
BIPAP or CPAP SUBSEQUENT,4360052,CDM,410,RC,94660,HCPCS,Outpatient,,,2044.8,1226.88,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1431.36,70,,,percent of total billed charges,70% of total billed charges,1533.6,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1635.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1564.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,352.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,920.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1431.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1226.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1431.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,981.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1840.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,320.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,1840.32,
VAPOTHERM DAILY ADULT,4360057,CDM,460,RC,94660,HCPCS,Outpatient,,,2306.88,1384.13,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1614.82,70,,,percent of total billed charges,70% of total billed charges,1730.16,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1845.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1764.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,397.48,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1038.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1614.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1384.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1614.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1107.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,2076.19,
IPPB TX SUBSEQUENT,4360091,CDM,410,RC,94640,HCPCS,Outpatient,,,280,168,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,616.28,
IPPB INITIAL,4360092,CDM,410,RC,94640,HCPCS,Outpatient,,,280,168,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,616.28,
PERCUSSION TX INITIAL,4360102,CDM,410,RC,94667,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
PERCUSSION TX SUBSEQ,4360103,CDM,410,RC,94668,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
VAPOTHERM DAILY INFANT,4360104,CDM,410,RC,94660,HCPCS,Outpatient,,,3600.63,2160.38,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2520.44,70,,,percent of total billed charges,70% of total billed charges,2700.47,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2880.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,2754.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,620.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1620.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2520.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,2520.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1728.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,3240.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,564.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,3240.57,
PK FLOW METER 1X CHRG EDU,4361002,CDM,270,RC,,,Outpatient,,,144,86.4,,25.92,18,,,percent of total billed charges,pays at 18% of total charges,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72,50,,,percent of total billed charges,pays at 50% of total billed charges,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,144,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.56,144,
INTUBATION ENDOTRACHEAL,4361500,CDM,410,RC,31500,HCPCS,Outpatient,,,584,350.4,,668.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,363.94,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,408.8,70,,,percent of total billed charges,70% of total billed charges,438,75,,,percent of total billed charges,75% of total billed charges,340.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.27,350,,,Fee Schedule,350% of CMS OPPS Rate,192.71,103,,,Fee Schedule,103% of CMS OPPS Rate,446.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,262.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,408.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,350.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,408.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,434.54,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,525.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,91.51,668.83,
OXYGEN PER HOUR,4362001,CDM,270,RC,,,Outpatient,,,36.5,21.9,,6.57,18,,,percent of total billed charges,pays at 18% of total charges,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.25,50,,,percent of total billed charges,pays at 50% of total billed charges,25.55,70,,,percent of total billed charges,70% of total billed charges,27.38,75,,,percent of total billed charges,75% of total billed charges,18.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,29.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,27.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,36.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,32.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,36.5,
NITRIC OXIDE PER HOUR,4362016,CDM,272,RC,,,Outpatient,,,850,510,,153,18,,,percent of total billed charges,pays at 18% of total charges,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,425,50,,,percent of total billed charges,pays at 50% of total billed charges,595,70,,,percent of total billed charges,70% of total billed charges,637.5,75,,,percent of total billed charges,75% of total billed charges,425,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,650.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,595,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,510,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,850,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,765,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,133.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,850,
STERILE WATER IRRIG PB 1000ML,4362017,CDM,272,RC,,,Outpatient,,,301,180.6,,54.18,18,,,percent of total billed charges,pays at 18% of total charges,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.5,50,,,percent of total billed charges,pays at 50% of total billed charges,210.7,70,,,percent of total billed charges,70% of total billed charges,225.75,75,,,percent of total billed charges,75% of total billed charges,150.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,240.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,180.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,230.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,210.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,180.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,301,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,270.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.17,301,
VENT MGMT INITIAL DAY,4363002,CDM,460,RC,94002,HCPCS,Outpatient,,,2484,1490.4,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1738.8,70,,,percent of total billed charges,70% of total billed charges,1863,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1987.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1900.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,427.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1117.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1738.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1490.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1738.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1192.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2235.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,389.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,389.24,2235.6,
VENT MGMT SUBSEQ DAY,4363003,CDM,460,RC,94003,HCPCS,Outpatient,,,2376,1425.6,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1663.2,70,,,percent of total billed charges,70% of total billed charges,1782,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1900.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,1817.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,409.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1663.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1425.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1663.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2138.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,372.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,372.32,2138.4,
VENT MGMT INITIAL DAY NEONATE,4363041,CDM,410,RC,94002,HCPCS,Outpatient,,,2854.08,1712.45,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1997.86,70,,,percent of total billed charges,70% of total billed charges,2140.56,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2283.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2183.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,491.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1284.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1997.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1712.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1997.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,2568.67,
VENT MGMT SUBSEQ DAY NEONATE,4363042,CDM,410,RC,94003,HCPCS,Outpatient,,,2710.08,1626.05,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1897.06,70,,,percent of total billed charges,70% of total billed charges,2032.56,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2168.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2073.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,466.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1219.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1897.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1626.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1897.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2439.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,2439.07,
VENT MGMT INITIAL DAY PEDI,4363043,CDM,410,RC,94002,HCPCS,Outpatient,,,2854.08,1712.45,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1997.86,70,,,percent of total billed charges,70% of total billed charges,2140.56,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2283.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2183.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,491.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1284.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1997.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1712.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1997.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,447.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,2568.67,
VENT MGMT SUBSEQ DAY PEDI,4363044,CDM,410,RC,94003,HCPCS,Outpatient,,,2710.08,1626.05,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1897.06,70,,,percent of total billed charges,70% of total billed charges,2032.56,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2168.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2073.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,466.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1219.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1897.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1626.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1897.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2439.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,424.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,2439.07,
VAPOTHERM INITIAL ADULT,4363045,CDM,460,RC,94660,HCPCS,Outpatient,,,2522.88,1513.73,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1766.02,70,,,percent of total billed charges,70% of total billed charges,1892.16,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2018.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1930,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,434.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1766.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1513.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1766.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1210.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2270.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,2270.59,
VAPOTHERM INITIAL INFANT,4363046,CDM,410,RC,94660,HCPCS,Outpatient,,,2834.64,1700.78,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1984.25,70,,,percent of total billed charges,70% of total billed charges,2125.98,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2267.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,2168.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,488.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1984.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1700.78,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1984.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2551.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,444.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,2551.18,
EZPAP INITIAL,4363047,CDM,410,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
EZPAP SUBSEQ,4363048,CDM,460,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
FLUTTER VALVE 1 TIME CHARGE,4363049,CDM,272,RC,,,Outpatient,,,175.05,105.03,,31.51,18,,,percent of total billed charges,pays at 18% of total charges,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.51,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.53,50,,,percent of total billed charges,pays at 50% of total billed charges,122.54,70,,,percent of total billed charges,70% of total billed charges,131.29,75,,,percent of total billed charges,75% of total billed charges,87.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,140.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,133.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,175.05,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,157.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.43,175.05,
HFOV OSCILLATOR SUBSEQUENT DAY,4363051,CDM,460,RC,94003,HCPCS,Outpatient,,,2808,1684.8,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1965.6,70,,,percent of total billed charges,70% of total billed charges,2106,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2246.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2148.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,483.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1263.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1965.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1684.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1965.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2527.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,440.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,422,2527.2,
CODE BLUE - NOT ER,4364015,CDM,480,RC,92950,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,1196,
HFOV OSCILLATOR INITIAL DAY,4364051,CDM,410,RC,94002,HCPCS,Outpatient,,,3301.2,1980.72,,1791.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,506.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,939.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,2310.84,70,,,percent of total billed charges,70% of total billed charges,2475.9,75,,,percent of total billed charges,75% of total billed charges,911,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2640.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1771.39,350,,,Fee Schedule,350% of CMS OPPS Rate,516.23,103,,,Fee Schedule,103% of CMS OPPS Rate,2525.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,568.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2310.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1980.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,2310.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1584.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2971.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,506.11,100,,,Fee Schedule,100% of CMS OPPS Rate,313,2971.08,
BIPAP or CPAP INITIAL,4364052,CDM,410,RC,94660,HCPCS,Outpatient,,,2098.8,1259.28,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1469.16,70,,,percent of total billed charges,70% of total billed charges,1574.1,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1679.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1605.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,361.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,944.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1469.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1259.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,1469.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1007.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1888.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,328.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,1888.92,
02 ER,4364090,CDM,270,RC,,,Outpatient,,,135.5,81.3,,24.39,18,,,percent of total billed charges,pays at 18% of total charges,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.75,50,,,percent of total billed charges,pays at 50% of total billed charges,94.85,70,,,percent of total billed charges,70% of total billed charges,101.63,75,,,percent of total billed charges,75% of total billed charges,67.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.98,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,135.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.23,135.5,
AIRVO INITIAL ADULT,4364660,CDM,460,RC,94660,HCPCS,Outpatient,,,2523,1513.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1766.1,70,,,percent of total billed charges,70% of total billed charges,1892.25,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2018.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1930.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,434.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1766.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1513.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1766.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1211.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2270.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,395.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,2270.7,
AIRVO DAILY  ADULT,4364661,CDM,460,RC,94660,HCPCS,Outpatient,,,2307,1384.2,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1614.9,70,,,percent of total billed charges,70% of total billed charges,1730.25,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1845.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,1764.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,397.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1038.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1614.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1384.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,1614.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1107.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,2076.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,361.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,2076.3,
NEBULIZER TX INITIAL,4365050,CDM,460,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
AEROSOL SPUTUM COLLECT,4365051,CDM,300,RC,89220,HCPCS,Outpatient,,,156,93.6,,506.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,109.2,70,,,percent of total billed charges,70% of total billed charges,117,75,,,percent of total billed charges,75% of total billed charges,257.32,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,500.34,350,,,Fee Schedule,350% of CMS OPPS Rate,145.81,103,,,Fee Schedule,103% of CMS OPPS Rate,119.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,70.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,116.26,100,,,Fee Schedule,100% of UHC Fee Schedule,109.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,328.79,100,,,Fee Schedule,100% of CMS OPPS Rate,74.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,140.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,12.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,142.95,100,,,Fee Schedule,100% of CMS OPPS Rate,12.94,506.06,
MDI INITIAL,4365054,CDM,460,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
NEBULIZER TX SUBSEQUENT,4365055,CDM,460,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
MDI DAILY,4365057,CDM,460,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
PENTAMIDINE FILTERED NEB TX,4365150,CDM,410,RC,94642,HCPCS,Outpatient,,,280,168,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,616.28,
NEBULIZER TX  INITIAL FIRST HOUR,4365350,CDM,410,RC,94644,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
NEBULIZER TX SUBSEQUENT EA ADD HOUR,4365355,CDM,410,RC,94645,HCPCS,Outpatient,,,139,83.4,,25.02,18,,,percent of total billed charges,pays at 18% of total charges,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.3,70,,,percent of total billed charges,70% of total billed charges,104.25,75,,,percent of total billed charges,75% of total billed charges,69.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313,100,,,Case rate,Pays based on per visit ,97.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.78,313,
NEBULIZER INITIAL,4365450,CDM,410,RC,94640,HCPCS,Outpatient,,,498,298.8,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,348.6,70,,,percent of total billed charges,70% of total billed charges,373.5,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,398.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,380.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,348.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,239.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,448.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,78.04,616.28,
NEBULIZER TX SUBSEQUENT,4365455,CDM,410,RC,94640,HCPCS,Outpatient,,,280,168,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,616.28,
ARTERIAL PUNCTURE,4366000,CDM,300,RC,36600,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,24.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,24.68,373.66,
PULSE OXIMETER SPOT CHECK,4366208,CDM,410,RC,94760,HCPCS,Outpatient,,,61.2,36.72,,11.02,18,,,percent of total billed charges,pays at 18% of total charges,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.84,70,,,percent of total billed charges,70% of total billed charges,45.9,75,,,percent of total billed charges,75% of total billed charges,30.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,48.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313,100,,,Case rate,Pays based on per visit ,42.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,55.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.59,313,
PULSE OX CONTINUOUS MONITOR,4366300,CDM,410,RC,94762,HCPCS,Outpatient,,,374,224.4,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,261.8,70,,,percent of total billed charges,70% of total billed charges,280.5,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,286.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,168.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,179.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,336.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,58.61,468.02,
NEBULIZER AEROGEN SET UP,4366400,CDM,270,RC,,,Outpatient,,,23.98,14.39,,4.32,18,,,percent of total billed charges,pays at 18% of total charges,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.99,50,,,percent of total billed charges,pays at 50% of total billed charges,16.79,70,,,percent of total billed charges,70% of total billed charges,17.99,75,,,percent of total billed charges,75% of total billed charges,11.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,19.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,16.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.39,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.98,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,21.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,3.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.76,23.98,
PRODUCTIVITY RESP X15MIN INCREMENTS,4367900,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Test to measure arterial blood gases,4369000,CDM,300,RC,82803,HCPCS,Outpatient,,,290.79,174.47,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges,218.09,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,222.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of UHC Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,139.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,261.71,
Test to measure arterial blood gases,4369001,CDM,300,RC,82803,HCPCS,Outpatient,,,290.79,174.47,,92.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges,218.09,75,,,percent of total billed charges,75% of total billed charges,46.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,232.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.24,350,,,Fee Schedule,350% of CMS OPPS Rate,26.59,102,,,Fee Schedule,102% of CMS OPPS Rate,222.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of UHC Fee Schedule,203.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.96,230,,,Fee Schedule,230% of CMS OPPS Rate,139.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,261.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,6.35,261.71,
LACTIC ACID LACTATE SERUM,4369001,CDM,300,RC,83605,HCPCS,Outpatient,,,207,124.2,,40.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,20.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.49,350,,,Fee Schedule,350% of CMS OPPS Rate,11.8,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.87,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,186.3,
SODIUM SERUM,4369001,CDM,300,RC,84295,HCPCS,Outpatient,,,73.8,44.28,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,350,,,Fee Schedule,350% of CMS OPPS Rate,4.9,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,66.42,
CHLORIDE SERUM,4369001,CDM,300,RC,82435,HCPCS,Outpatient,,,63.45,38.07,,16.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,8.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.09,350,,,Fee Schedule,350% of CMS OPPS Rate,4.69,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,57.11,
Quantitative measure of glucose build up in the blood over time,4369001,CDM,300,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
POTASSIUM BLOOD,4369001,CDM,300,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
CALCIUM IONIZED ABGS,4369001,CDM,300,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
CALCIUM IONIZED ABGS,4369002,CDM,300,RC,82330,HCPCS,Outpatient,,,72.9,43.74,,48.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges,54.68,75,,,percent of total billed charges,75% of total billed charges,24.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.88,350,,,Fee Schedule,350% of CMS OPPS Rate,13.95,102,,,Fee Schedule,102% of CMS OPPS Rate,55.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,32.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of UHC Fee Schedule,51.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,31.46,230,,,Fee Schedule,230% of CMS OPPS Rate,34.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.68,65.61,
POTASSIUM BLOOD,4369003,CDM,300,RC,84132,HCPCS,Outpatient,,,52.2,31.32,,16.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.76,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges,39.15,75,,,percent of total billed charges,75% of total billed charges,8.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.66,350,,,Fee Schedule,350% of CMS OPPS Rate,4.85,102,,,Fee Schedule,102% of CMS OPPS Rate,39.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,23.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,36.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,10.94,230,,,Fee Schedule,230% of CMS OPPS Rate,25.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,46.98,
Quantitative measure of glucose build up in the blood over time,4369004,CDM,300,RC,82947,HCPCS,Outpatient,,,152.35,91.41,,13.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges,114.26,75,,,percent of total billed charges,75% of total billed charges,7.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.75,350,,,Fee Schedule,350% of CMS OPPS Rate,4,102,,,Fee Schedule,102% of CMS OPPS Rate,116.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,68.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4.37,100,,,Fee Schedule,100% of UHC Fee Schedule,106.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.03,230,,,Fee Schedule,230% of CMS OPPS Rate,73.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,137.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,137.12,
CHLORIDE SERUM,4369005,CDM,300,RC,82435,HCPCS,Outpatient,,,63.45,38.07,,16.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,8.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.09,350,,,Fee Schedule,350% of CMS OPPS Rate,4.69,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,5.11,100,,,Fee Schedule,100% of UHC Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,4.59,57.11,
LACTIC ACID LACTATE SERUM,4369006,CDM,300,RC,83605,HCPCS,Outpatient,,,207,124.2,,40.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.57,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,20.82,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.49,350,,,Fee Schedule,350% of CMS OPPS Rate,11.8,102,,,Fee Schedule,102% of CMS OPPS Rate,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.87,100,,,Fee Schedule,100% of UHC Fee Schedule,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,26.61,230,,,Fee Schedule,230% of CMS OPPS Rate,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.57,186.3,
SODIUM SERUM,4369007,CDM,300,RC,84295,HCPCS,Outpatient,,,73.8,44.28,,17.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4.81,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges,55.35,75,,,percent of total billed charges,75% of total billed charges,8.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.83,350,,,Fee Schedule,350% of CMS OPPS Rate,4.9,102,,,Fee Schedule,102% of CMS OPPS Rate,56.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,33.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5.35,100,,,Fee Schedule,100% of UHC Fee Schedule,51.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11.06,230,,,Fee Schedule,230% of CMS OPPS Rate,35.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,66.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.81,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4.8,66.42,
Measures how much air is in the lungs after taking a deep breath,4370021,CDM,460,RC,94726,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
PULMONARY COMPLIANCE,4370022,CDM,460,RC,94750,HCPCS,Outpatient,,,280.94,168.56,,,,,,Other,Not Separately reimbursable,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196.66,70,,,percent of total billed charges,70% of total billed charges,210.71,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,224.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,196.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,252.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.02,422,
Test to measure how well gases diffuse across lung surfaces,4374000E,CDM,460,RC,94729,HCPCS,Outpatient,,,214,128.4,,,,,,Other,Not Separately reimbursable,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,422,
Measures how much air is in the lungs after taking a deep breath,4374000E,CDM,460,RC,94726,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
Test to determine if wheezing is present,4374000E,CDM,460,RC,94060,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
Test to measure how well gases diffuse across lung surfaces,4375000E,CDM,460,RC,94729,HCPCS,Outpatient,,,214,128.4,,,,,,Other,Not Separately reimbursable,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,422,
Test to determine how well oxygen moves from the lungs to the blood stream,4375000E,CDM,460,RC,94010,HCPCS,Outpatient,,,374,224.4,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,261.8,70,,,percent of total billed charges,70% of total billed charges,280.5,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.85,103,,,Fee Schedule,103% of CMS OPPS Rate,286.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,168.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.08,100,,,Fee Schedule,100% of CMS OPPS Rate,179.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,336.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,58.61,468.02,
Test to measure how well gases diffuse across lung surfaces,4376000E,CDM,460,RC,94729,HCPCS,Outpatient,,,214,128.4,,,,,,Other,Not Separately reimbursable,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,422,
Test to determine if wheezing is present,4376000E,CDM,460,RC,94060,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
PULMONARY STRESS TEST,4378045,CDM,460,RC,94621,HCPCS,Outpatient,,,1179.36,707.62,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,825.55,70,,,percent of total billed charges,70% of total billed charges,884.52,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,943.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,902.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,203.2,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,530.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,825.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,707.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,825.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,566.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,184.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,184.81,1061.42,
CARDIO-STRESS TEST,4378046,CDM,482,RC,93017,HCPCS,Outpatient,,,719.2,431.52,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,503.44,70,,,percent of total billed charges,70% of total billed charges,539.4,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,575.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,550.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,323.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,503.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,431.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1178,100,,,Case rate,Pays based on per visit ,503.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,345.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,647.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,112.7,1178,
PULMONARY STRESS TEST SIMPLE,4378047,CDM,460,RC,94618,HCPCS,Outpatient,,,288.5,173.1,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,201.95,70,,,percent of total billed charges,70% of total billed charges,216.38,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,230.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,220.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,129.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,201.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,201.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,138.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,259.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,45.21,422,
Test to measure how well gases diffuse across lung surfaces,4379109,CDM,460,RC,94729,HCPCS,Outpatient,,,214,128.4,,,,,,Other,Not Separately reimbursable,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,422,
Test to measure how well gases diffuse across lung surfaces,4379119E,CDM,460,RC,94729,HCPCS,Outpatient,,,214,128.4,,,,,,Other,Not Separately reimbursable,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,422,
Measures how much air is in the lungs after taking a deep breath,4379119E,CDM,460,RC,94726,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
Test to determine how well oxygen moves from the lungs to the blood stream,4379119E,CDM,460,RC,94010,HCPCS,Outpatient,,,374,224.4,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,261.8,70,,,percent of total billed charges,70% of total billed charges,280.5,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.85,103,,,Fee Schedule,103% of CMS OPPS Rate,286.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,168.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.08,100,,,Fee Schedule,100% of CMS OPPS Rate,179.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,336.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,58.61,468.02,
Test to determine how well oxygen moves from the lungs to the blood stream,4379121,CDM,460,RC,94010,HCPCS,Outpatient,,,374,224.4,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,261.8,70,,,percent of total billed charges,70% of total billed charges,280.5,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,299.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.85,103,,,Fee Schedule,103% of CMS OPPS Rate,286.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,168.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,224.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,261.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.08,100,,,Fee Schedule,100% of CMS OPPS Rate,179.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,336.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,58.61,468.02,
PULMO FUNCT BRONCHIAL CHALLENGE,4379122,CDM,924,RC,95070,HCPCS,Outpatient,,,1314,788.4,,1555.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,439.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,906.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,919.8,70,,,percent of total billed charges,70% of total billed charges,985.5,75,,,percent of total billed charges,75% of total billed charges,791.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1051.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1538.19,350,,,Fee Schedule,350% of CMS OPPS Rate,448.26,103,,,Fee Schedule,103% of CMS OPPS Rate,1005.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,226.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,591.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,919.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,711,100,,,Case rate,Pays based on per visit ,919.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.81,100,,,Fee Schedule,100% of CMS OPPS Rate,630.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,1182.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,205.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,439.48,100,,,Fee Schedule,100% of CMS OPPS Rate,205.9,1555.77,
Test to determine if wheezing is present,4379920,CDM,460,RC,94060,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
STRAPPING FINGER OR HAND,4400407,CDM,430,RC,29280,HCPCS,Outpatient,,,121.05,72.63,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,84.74,70,,,percent of total billed charges,70% of total billed charges,90.79,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,92.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,54.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,84.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,58.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,108.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,18.97,191,
COGNITIVE RETRAIN OT INI 15M,4408880,CDM,434,RC,97129,HCPCS,Outpatient,,,85.86,51.52,,77.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.93,50,,,percent of total billed charges,pays at 50% of total billed charges,60.1,70,,,percent of total billed charges,70% of total billed charges,64.4,75,,,percent of total billed charges,75% of total billed charges,39.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.22,102,,,Fee Schedule,102% of CMS OPPS Rate,65.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,230,,,Fee Schedule,230% of CMS OPPS Rate,41.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,77.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.45,191,
OT RE EVAL,4408881,CDM,434,RC,97168,HCPCS,Outpatient,,,105.42,63.25,,233.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.79,70,,,percent of total billed charges,70% of total billed charges,79.07,75,,,percent of total billed charges,75% of total billed charges,118.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.44,350,,,Fee Schedule,350% of CMS OPPS Rate,67.16,102,,,Fee Schedule,102% of CMS OPPS Rate,80.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,73.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,151.43,230,,,Fee Schedule,230% of CMS OPPS Rate,50.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,94.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.44,233.07,
COGNITIVE RETRAIN OT ADD 15M,4408883,CDM,434,RC,97130,HCPCS,Outpatient,,,80,48,,74.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,37.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.85,350,,,Fee Schedule,350% of CMS OPPS Rate,21.52,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,48.53,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,191,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",4408886,CDM,431,RC,97530,HCPCS,Outpatient,,,113,67.8,,123.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,62.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.12,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,80.25,230,,,Fee Schedule,230% of CMS OPPS Rate,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,191,
MOBILITY CURRENT OT,4409100,CDM,430,RC,G8978,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY GOAL OT,4409101,CDM,430,RC,G8979,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY D/C OT,4409102,CDM,430,RC,G8980,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS CURRENT OT,4409110,CDM,430,RC,G8981,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS GOAL OT,4409111,CDM,430,RC,G8982,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS D/C OT,4409112,CDM,430,RC,G8983,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY CURRENT OT,4409120,CDM,430,RC,G8984,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY GOAL OT,4409121,CDM,430,RC,G8985,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY D/C OT,4409122,CDM,430,RC,G8986,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE CURRENT OT,4409130,CDM,430,RC,G8987,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE GOAL OT,4409131,CDM,430,RC,G8988,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE D/C OT,4409132,CDM,430,RC,G8989,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT CURRENT OT,4409140,CDM,430,RC,G8990,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT GOAL OT,4409141,CDM,430,RC,G8991,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT D/C OT,4409142,CDM,430,RC,G8992,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT CURRENT OT,4409150,CDM,430,RC,G8993,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT GOAL OT,4409151,CDM,430,RC,G8994,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT D/C OT,4409152,CDM,430,RC,G8995,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
PT EVAL HIGH COMP 45MIN WH,4409200,CDM,424,RC,97163,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4409202,CDM,420,RC,97110,HCPCS,Outpatient,,,89,53.4,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
Repeated application to one or more parts of the body,4409204,CDM,420,RC,97032,HCPCS,Outpatient,,,48.4,29.04,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.88,70,,,percent of total billed charges,70% of total billed charges,36.3,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,37.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,33.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,23.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,43.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,191,
A technique used by physical therapists to restore normal body movement patterns,4409206,CDM,420,RC,97112,HCPCS,Outpatient,,,103,61.8,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,16.14,191,
PT RE EVAL WH,4409208,CDM,424,RC,97164,HCPCS,Outpatient,,,85.95,51.57,,234.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.17,70,,,percent of total billed charges,70% of total billed charges,64.46,75,,,percent of total billed charges,75% of total billed charges,119.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.49,350,,,Fee Schedule,350% of CMS OPPS Rate,67.46,102,,,Fee Schedule,102% of CMS OPPS Rate,65.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,152.12,230,,,Fee Schedule,230% of CMS OPPS Rate,41.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,234.14,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",4409210,CDM,421,RC,97035,HCPCS,Outpatient,,,42,25.2,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.58,191,
Manipulation of 1 or more regions of the body,4409212,CDM,421,RC,97140,HCPCS,Outpatient,,,83,49.8,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,191,
PT EVAL LOW COMP WH,4409214,CDM,424,RC,97161,HCPCS,Outpatient,,,83,49.8,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,339.42,
PT EVAL MOD COMP 30MIN WH,4409215,CDM,424,RC,97162,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
MOBILITY CURRENT PT,4409300,CDM,420,RC,G8978,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY GOAL PT,4409301,CDM,420,RC,G8979,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY D/C PT,4409302,CDM,420,RC,G8980,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS CURRENT PT,4409310,CDM,420,RC,G8981,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS GOAL PT,4409311,CDM,420,RC,G8982,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS D/C PT,4409312,CDM,420,RC,G8983,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY CURRENT PT,4409320,CDM,420,RC,G8984,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY GOAL PT,4409321,CDM,420,RC,G8985,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY D/C PT,4409322,CDM,420,RC,G8986,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE CURRENT PT,4409330,CDM,420,RC,G8987,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE GOAL PT,4409331,CDM,420,RC,G8988,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE D/C PT,4409332,CDM,420,RC,G8989,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT CURRENT PT,4409340,CDM,420,RC,G8990,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT GOAL PT,4409341,CDM,420,RC,G8991,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT D/C PT,4409342,CDM,420,RC,G8992,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT CURRENT PT,4409350,CDM,420,RC,G8993,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT GOAL PT,4409351,CDM,420,RC,G8994,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT D/C PT,4409352,CDM,420,RC,G8995,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
Manipulation of 1 or more regions of the body,4409516,CDM,430,RC,97140,HCPCS,Outpatient,,,74.12,44.47,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.88,70,,,percent of total billed charges,70% of total billed charges,55.59,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,56.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,35.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,66.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,191,
SWALLOW CURRENT STATUS,4409520,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SWALLOW GOAL STATUS,4409521,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SWALLOW D/C STATUS,4409522,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOTOR SPEECH CURRENT STATUS,4409530,CDM,440,RC,G8999,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOTOR SPEECH GOAL STATUS,4409531,CDM,440,RC,G9186,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOTOR SPEECH D/C STATUS,4409532,CDM,440,RC,G9158,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
STRAPPING ELBOW OR WRIST,4409535,CDM,430,RC,29260,HCPCS,Outpatient,,,98.26,58.96,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,68.78,70,,,percent of total billed charges,70% of total billed charges,73.7,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,75.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,47.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,88.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,15.4,191,
LANG COMP CURRENT STATUS,4409540,CDM,440,RC,G9159,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG COMP GOAL STATUS,4409541,CDM,440,RC,G9160,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG COMP D/C STATUS,4409542,CDM,440,RC,G9161,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OT GROUP,4409545,CDM,440,RC,97150,HCPCS,Outpatient,,,44,26.4,,60.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,30.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,350,,,Fee Schedule,350% of CMS OPPS Rate,17.38,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.19,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,191,
LANG EXPRESS CURRENT STATUS,4409550,CDM,440,RC,G9162,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG EXPRESS GOAL STATUS,4409551,CDM,440,RC,G9163,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG EXPRESS D/C STATUS,4409552,CDM,440,RC,G9164,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ATTEN CURRENT STATUS,4409560,CDM,440,RC,G9165,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ATTEN GOAL STATUS,4409561,CDM,440,RC,G9166,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ATTEN D/C STATUS,4409562,CDM,440,RC,G9167,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MEMORY CURRENT STATUS,4409570,CDM,440,RC,G9168,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MEMORY GOAL STATUS,4409571,CDM,440,RC,G9169,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MEMORY D/C STATUS,4409572,CDM,440,RC,G9170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
Occupational therapy,4409575,CDM,431,RC,97535,HCPCS,Outpatient,,,99,59.4,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.51,191,
VOICE CURRENT STATUS,4409580,CDM,440,RC,G9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
VOICE GOAL STATUS,4409581,CDM,440,RC,G9172,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
VOICE D/C STATUS,4409582,CDM,440,RC,G9173,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SPEECH LANG CURRENT STATUS,4409590,CDM,440,RC,G9174,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SPEECH LANG GOAL STATUS,4409591,CDM,440,RC,G9175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SPEECH LANG D/C STATUS,4409592,CDM,440,RC,G9176,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BURN TX SMALL LESS THAN 5 PRCNT BS AREA,4409612,CDM,360,RC,16020,HCPCS,Outpatient,,,178,106.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,124.6,70,,,percent of total billed charges,70% of total billed charges,133.5,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,136.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,124.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,85.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,657,
BURN TX MED 5 TO 10 PRCNT BS AREA,4409613,CDM,360,RC,16025,HCPCS,Outpatient,,,189.2,113.52,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,132.44,70,,,percent of total billed charges,70% of total billed charges,141.9,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,151.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,144.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,85.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,132.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,90.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,170.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,85.14,657,
BURN TX LRG GRTR THAN 10 PRCNT BS AREA,4409614,CDM,360,RC,16030,HCPCS,Outpatient,,,259.68,155.81,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,259.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,181.78,70,,,percent of total billed charges,70% of total billed charges,194.76,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,207.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,259.68,103,,,Fee Schedule,103% of CMS OPPS Rate,198.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,116.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,181.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,181.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,124.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,259.68,100,,,Fee Schedule,100% of CMS OPPS Rate,233.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,116.86,1200.6,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",4409680,CDM,420,RC,97597,HCPCS,Outpatient,,,169.7,101.82,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.79,70,,,percent of total billed charges,70% of total billed charges,127.28,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,129.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,81.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,152.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,581.14,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",4409702,CDM,420,RC,97597,HCPCS,Outpatient,,,169.7,101.82,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.79,70,,,percent of total billed charges,70% of total billed charges,127.28,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,129.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,81.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,152.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,581.14,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",4409706,CDM,420,RC,97597,HCPCS,Outpatient,,,169.7,101.82,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.79,70,,,percent of total billed charges,70% of total billed charges,127.28,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,129.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,81.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,152.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,581.14,
SLCTV DEBRIDEM ADDL 20CM/<,4409707,CDM,420,RC,97598,HCPCS,Outpatient,,,183.52,110.11,,33.03,18,,,percent of total billed charges,pays at 18% of total charges,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.03,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.46,70,,,percent of total billed charges,70% of total billed charges,137.64,75,,,percent of total billed charges,75% of total billed charges,91.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,146.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,128.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,183.52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.76,191,
NON-SELECTIVE WND DEBRIDE,4409710,CDM,420,RC,97602,HCPCS,Outpatient,,,134.4,80.64,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,134.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,94.08,70,,,percent of total billed charges,70% of total billed charges,100.8,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,107.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,134.4,103,,,Fee Schedule,103% of CMS OPPS Rate,102.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,94.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,94.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,64.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,134.4,100,,,Fee Schedule,100% of CMS OPPS Rate,120.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,21.06,581.14,
NON WND ELECT STIM,4409714,CDM,420,RC,G0283,HCPCS,Outpatient,,,62.37,37.42,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,191,
Repeated application to one or more parts of the body,4409715,CDM,420,RC,97032,HCPCS,Outpatient,,,69.3,41.58,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.51,70,,,percent of total billed charges,70% of total billed charges,51.98,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,53.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,48.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,33.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.86,191,
E-STIM W/HEAT - PT,4409719,CDM,420,RC,G0283,HCPCS,Outpatient,,,62.37,37.42,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4409722,CDM,420,RC,97110,HCPCS,Outpatient,,,90.63,54.38,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.44,70,,,percent of total billed charges,70% of total billed charges,67.97,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,69.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,43.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,81.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
Manipulation of 1 or more regions of the body,4409723,CDM,421,RC,97140,HCPCS,Outpatient,,,83,49.8,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,191,
A type of physical therapy,4409724,CDM,421,RC,97116,HCPCS,Outpatient,,,89,53.4,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.95,191,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",4409725,CDM,421,RC,97530,HCPCS,Outpatient,,,113,67.8,,123.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,62.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.12,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,80.25,230,,,Fee Schedule,230% of CMS OPPS Rate,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,191,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",4409726,CDM,421,RC,97035,HCPCS,Outpatient,,,55.44,33.26,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.81,70,,,percent of total billed charges,70% of total billed charges,41.58,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,42.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,38.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,26.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,49.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8.69,191,
CANALITH REPOSITIONING,4409728,CDM,420,RC,95992,HCPCS,Outpatient,,,115,69,,124.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.5,70,,,percent of total billed charges,70% of total billed charges,86.25,75,,,percent of total billed charges,75% of total billed charges,63.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.45,350,,,Fee Schedule,350% of CMS OPPS Rate,35.98,102,,,Fee Schedule,102% of CMS OPPS Rate,87.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,51.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,81.12,230,,,Fee Schedule,230% of CMS OPPS Rate,55.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,103.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,18.02,191,
Use of massage,4409735,CDM,420,RC,97124,HCPCS,Outpatient,,,82,49.2,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,191,
Use of massage,4409736,CDM,421,RC,97124,HCPCS,Outpatient,,,82,49.2,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,191,
PT RE EVAL,4409741,CDM,424,RC,97164,HCPCS,Outpatient,,,170,102,,234.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,119,70,,,percent of total billed charges,70% of total billed charges,127.5,75,,,percent of total billed charges,75% of total billed charges,119.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.49,350,,,Fee Schedule,350% of CMS OPPS Rate,67.46,102,,,Fee Schedule,102% of CMS OPPS Rate,130.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,76.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,119,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,152.12,230,,,Fee Schedule,230% of CMS OPPS Rate,81.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,153,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,50.38,234.14,
ORTHOTIC MGMT/TR 15M-PT,4409744,CDM,420,RC,97760,HCPCS,Outpatient,,,98.4,59.04,,160.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.88,70,,,percent of total billed charges,70% of total billed charges,73.8,75,,,percent of total billed charges,75% of total billed charges,81.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.31,350,,,Fee Schedule,350% of CMS OPPS Rate,46.13,102,,,Fee Schedule,102% of CMS OPPS Rate,75.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,44.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,104.03,230,,,Fee Schedule,230% of CMS OPPS Rate,47.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,88.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,191,
A technique used by physical therapists to restore normal body movement patterns,4409747,CDM,420,RC,97112,HCPCS,Outpatient,,,103,61.8,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,16.14,191,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",4409757,CDM,421,RC,97035,HCPCS,Outpatient,,,55.44,33.26,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.81,70,,,percent of total billed charges,70% of total billed charges,41.58,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,42.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,38.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,26.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,49.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8.69,191,
MODALITY - WHIRLPOOL,4409758,CDM,421,RC,97022,HCPCS,Outpatient,,,77.45,46.47,,56.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.22,70,,,percent of total billed charges,70% of total billed charges,58.09,75,,,percent of total billed charges,75% of total billed charges,28.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,59.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,34.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,54.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,230,,,Fee Schedule,230% of CMS OPPS Rate,37.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,69.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,12.14,191,
PT EVAL LOW COMPLEXITY,4409762,CDM,424,RC,97161,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
Occupational therapy,4409764,CDM,421,RC,97535,HCPCS,Outpatient,,,99,59.4,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.51,191,
PT EVAL MOD COMP 30MIN,4409767,CDM,424,RC,97162,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
PT EVAL HIGH COMP 45MIN,4409769,CDM,424,RC,97163,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
ELECTRICAL STIMULATION OT,4409814,CDM,430,RC,G0283,HCPCS,Outpatient,,,62.37,37.42,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,191,
A technique used by physical therapists to restore normal body movement patterns,4409820,CDM,430,RC,97112,HCPCS,Outpatient,,,103,61.8,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,16.14,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4409822,CDM,431,RC,97110,HCPCS,Outpatient,,,90.63,54.38,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.44,70,,,percent of total billed charges,70% of total billed charges,67.97,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,69.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,43.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,81.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
Occupational therapy,4409825,CDM,431,RC,97535,HCPCS,Outpatient,,,86.85,52.11,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges,65.14,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,66.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,41.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,191,
ORTHOTIC MGMT/TR 15M-OT,4409842,CDM,430,RC,97760,HCPCS,Outpatient,,,141,84.6,,160.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges,105.75,75,,,percent of total billed charges,75% of total billed charges,81.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.31,350,,,Fee Schedule,350% of CMS OPPS Rate,46.13,102,,,Fee Schedule,102% of CMS OPPS Rate,107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,63.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,104.03,230,,,Fee Schedule,230% of CMS OPPS Rate,67.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,126.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,191,
THERAPUTTY,4409851,CDM,272,RC,,,Outpatient,,,7.2,4.32,,1.3,18,,,percent of total billed charges,pays at 18% of total charges,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.6,50,,,percent of total billed charges,pays at 50% of total billed charges,5.04,70,,,percent of total billed charges,70% of total billed charges,5.4,75,,,percent of total billed charges,75% of total billed charges,3.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,5.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,5.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,6.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.13,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.13,7.2,
FUNCTIONAL HAND SPLINT,4409852,CDM,270,RC,L3807,HCPCS,Outpatient,,,136.5,81.9,,928.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.25,50,,,percent of total billed charges,pays at 50% of total billed charges,95.55,70,,,percent of total billed charges,70% of total billed charges,102.38,75,,,percent of total billed charges,75% of total billed charges,472.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.33,350,,,Fee Schedule,350% of CMS OPPS Rate,267.63,102,,,Fee Schedule,102% of CMS OPPS Rate,104.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,61.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,51.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,136.5,230,,,Fee Schedule,230% of CMS OPPS Rate,65.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,21.39,928.83,
WHFO-STATIC-PREFAB,4409854,CDM,270,RC,L3807,HCPCS,Outpatient,,,151,90.6,,928.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,50,,,percent of total billed charges,pays at 50% of total billed charges,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,472.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.33,350,,,Fee Schedule,350% of CMS OPPS Rate,267.63,102,,,Fee Schedule,102% of CMS OPPS Rate,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,151,230,,,Fee Schedule,230% of CMS OPPS Rate,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,100% of CMS OPPS Rate,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,23.66,928.83,
OT EVAL LOW COMPLEXITY,4409862,CDM,434,RC,97165,HCPCS,Outpatient,,,263,157.8,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.1,70,,,percent of total billed charges,70% of total billed charges,197.25,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,201.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,118.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,184.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,126.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,236.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
Occupational therapy,4409864,CDM,431,RC,97535,HCPCS,Outpatient,,,99,59.4,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.51,191,
OT EVAL MOD COMP 45MIN,4409868,CDM,434,RC,97166,HCPCS,Outpatient,,,262,157.2,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.4,70,,,percent of total billed charges,70% of total billed charges,196.5,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,200.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,117.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,125.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,235.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
OT EVAL HIGH COMP 60MIN,4409869,CDM,434,RC,97167,HCPCS,Outpatient,,,262,157.2,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.4,70,,,percent of total billed charges,70% of total billed charges,196.5,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,200.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,117.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,125.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,235.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
EVAL SPEECH FLUENCY,4409918,CDM,444,RC,92521,HCPCS,Outpatient,,,182.07,109.24,,451.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,127.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,234.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.45,70,,,percent of total billed charges,70% of total billed charges,136.55,75,,,percent of total billed charges,75% of total billed charges,229.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.29,350,,,Fee Schedule,350% of CMS OPPS Rate,130.06,102,,,Fee Schedule,102% of CMS OPPS Rate,139.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,81.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,127.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,293.27,230,,,Fee Schedule,230% of CMS OPPS Rate,87.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,163.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,451.39,
EVAL SPEECH PRODUCTION,4409919,CDM,444,RC,92522,HCPCS,Outpatient,,,272,163.2,,378.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,192.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.36,350,,,Fee Schedule,350% of CMS OPPS Rate,109.1,102,,,Fee Schedule,102% of CMS OPPS Rate,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,246.01,230,,,Fee Schedule,230% of CMS OPPS Rate,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,378.64,
Therapy for speech or hearing,4409922,CDM,440,RC,92507,HCPCS,Outpatient,,,293,175.8,,260.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.1,70,,,percent of total billed charges,70% of total billed charges,219.75,75,,,percent of total billed charges,75% of total billed charges,132.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.25,350,,,Fee Schedule,350% of CMS OPPS Rate,74.97,102,,,Fee Schedule,102% of CMS OPPS Rate,224.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,131.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.05,230,,,Fee Schedule,230% of CMS OPPS Rate,140.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,263.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.56,263.7,
MOTION FLUORO SWALLOW FCN,4409925,CDM,440,RC,92611,HCPCS,Outpatient,,,357,214.2,,309.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,87.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,180.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.9,70,,,percent of total billed charges,70% of total billed charges,267.75,75,,,percent of total billed charges,75% of total billed charges,157.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.87,350,,,Fee Schedule,350% of CMS OPPS Rate,89.14,102,,,Fee Schedule,102% of CMS OPPS Rate,273.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,201,230,,,Fee Schedule,230% of CMS OPPS Rate,171.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.36,321.3,
Evaluation of speech sound production with evaluation of language comprehension,4409928,CDM,444,RC,92523,HCPCS,Outpatient,,,567,340.2,,773.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,407.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,396.9,70,,,percent of total billed charges,70% of total billed charges,425.25,75,,,percent of total billed charges,75% of total billed charges,393.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765.1,350,,,Fee Schedule,350% of CMS OPPS Rate,222.97,102,,,Fee Schedule,102% of CMS OPPS Rate,433.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,396.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,396.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,502.78,230,,,Fee Schedule,230% of CMS OPPS Rate,272.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,510.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,773.84,
EVAL VOICE QUALITY,4409929,CDM,444,RC,92524,HCPCS,Outpatient,,,162.41,97.45,,374.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.69,70,,,percent of total billed charges,70% of total billed charges,121.81,75,,,percent of total billed charges,75% of total billed charges,190.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.2,350,,,Fee Schedule,350% of CMS OPPS Rate,107.89,102,,,Fee Schedule,102% of CMS OPPS Rate,124.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,243.27,230,,,Fee Schedule,230% of CMS OPPS Rate,77.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,146.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,374.43,
BEDSIDE SWALLOW EVAL ST,4409931,CDM,444,RC,92610,HCPCS,Outpatient,,,220,132,,239.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,121.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.5,350,,,Fee Schedule,350% of CMS OPPS Rate,68.92,102,,,Fee Schedule,102% of CMS OPPS Rate,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,155.41,230,,,Fee Schedule,230% of CMS OPPS Rate,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,37.16,239.2,
TREAT SWALLOW DYSFUNC-15M,4409932,CDM,440,RC,92526,HCPCS,Outpatient,,,256,153.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.12,287.06,
SPEECH/HEARING SCREEN,4409941,CDM,440,RC,92551,HCPCS,Outpatient,,,157.95,94.77,,28.43,18,,,percent of total billed charges,pays at 18% of total charges,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.43,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.57,70,,,percent of total billed charges,70% of total billed charges,118.46,75,,,percent of total billed charges,75% of total billed charges,78.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,110.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,157.95,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.02,191,
TREAT SWALLOW DYSFUNC-30M,4409945,CDM,440,RC,92526,HCPCS,Outpatient,,,256,153.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.12,287.06,
Therapy for speech or hearing,4409950,CDM,440,RC,92507,HCPCS,Outpatient,,,233,139.8,,260.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,163.1,70,,,percent of total billed charges,70% of total billed charges,174.75,75,,,percent of total billed charges,75% of total billed charges,132.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.25,350,,,Fee Schedule,350% of CMS OPPS Rate,74.97,102,,,Fee Schedule,102% of CMS OPPS Rate,178.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,163.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.05,230,,,Fee Schedule,230% of CMS OPPS Rate,111.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,209.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.56,260.19,
COGNITIVE TESTING PER HR,4409960,CDM,440,RC,96125,HCPCS,Outpatient,,,187.2,112.32,,347.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,244.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges,140.4,75,,,percent of total billed charges,75% of total billed charges,176.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.77,350,,,Fee Schedule,350% of CMS OPPS Rate,100.18,102,,,Fee Schedule,102% of CMS OPPS Rate,143.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,225.91,230,,,Fee Schedule,230% of CMS OPPS Rate,89.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,168.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.33,347.7,
EVAL SPEECH DEVICE TX (1 HR),4409961,CDM,444,RC,92607,HCPCS,Outpatient,,,144,86.4,,416.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,117.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,269.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,211.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,411.85,350,,,Fee Schedule,350% of CMS OPPS Rate,120.02,102,,,Fee Schedule,102% of CMS OPPS Rate,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,270.64,230,,,Fee Schedule,230% of CMS OPPS Rate,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,117.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.56,416.55,
EVAL SPEECH DEVICE TX (30 MIN),4409962,CDM,444,RC,92608,HCPCS,Outpatient,,,67.5,40.5,,163.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.25,70,,,percent of total billed charges,70% of total billed charges,50.63,75,,,percent of total billed charges,75% of total billed charges,83.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.56,350,,,Fee Schedule,350% of CMS OPPS Rate,47.08,102,,,Fee Schedule,102% of CMS OPPS Rate,51.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,30.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,47.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,106.17,230,,,Fee Schedule,230% of CMS OPPS Rate,32.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,191,
TRAIN WITH SPEECH DEVICE,4409963,CDM,441,RC,92609,HCPCS,Outpatient,,,121.5,72.9,,347.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,225.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.05,70,,,percent of total billed charges,70% of total billed charges,91.13,75,,,percent of total billed charges,75% of total billed charges,176.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.32,350,,,Fee Schedule,350% of CMS OPPS Rate,100.05,102,,,Fee Schedule,102% of CMS OPPS Rate,92.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,54.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,225.61,230,,,Fee Schedule,230% of CMS OPPS Rate,58.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,109.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,347.24,
EVAL NON SPEECH DEVICE,4409964,CDM,444,RC,92605,HCPCS,Outpatient,,,144,86.4,,296.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72,50,,,percent of total billed charges,pays at 50% of total billed charges,100.8,70,,,percent of total billed charges,70% of total billed charges,108,75,,,percent of total billed charges,75% of total billed charges,150.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,115.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,293.13,350,,,Fee Schedule,350% of CMS OPPS Rate,85.43,102,,,Fee Schedule,102% of CMS OPPS Rate,110.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,64.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,100.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,192.63,230,,,Fee Schedule,230% of CMS OPPS Rate,69.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,129.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,83.75,100,,,Fee Schedule,100% of CMS OPPS Rate,22.56,296.48,
TRAIN NON SPEECH DEVICE,4409965,CDM,441,RC,92606,HCPCS,Outpatient,,,121.5,72.9,,235.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,60.75,50,,,percent of total billed charges,pays at 50% of total billed charges,85.05,70,,,percent of total billed charges,70% of total billed charges,91.13,75,,,percent of total billed charges,75% of total billed charges,119.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233,350,,,Fee Schedule,350% of CMS OPPS Rate,67.9,102,,,Fee Schedule,102% of CMS OPPS Rate,92.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,54.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,85.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,153.11,230,,,Fee Schedule,230% of CMS OPPS Rate,58.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,109.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,100,,,Fee Schedule,100% of CMS OPPS Rate,19.04,235.66,
TREAT SWALLOW DYSFUNC 45M,4409970,CDM,440,RC,92526,HCPCS,Outpatient,,,256,153.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.12,287.06,
TREAT SWALLOW DYSFUNC 60M,4409975,CDM,440,RC,92526,HCPCS,Outpatient,,,256,153.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.12,287.06,
COGNITIVE RETRAIN ST INI 15M,4409981,CDM,440,RC,97129,HCPCS,Outpatient,,,85.86,51.52,,77.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.93,50,,,percent of total billed charges,pays at 50% of total billed charges,60.1,70,,,percent of total billed charges,70% of total billed charges,64.4,75,,,percent of total billed charges,75% of total billed charges,39.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.22,102,,,Fee Schedule,102% of CMS OPPS Rate,65.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,230,,,Fee Schedule,230% of CMS OPPS Rate,41.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,77.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.45,191,
COGNITIVE RETRAIN ST ADD 15M,4409982,CDM,440,RC,97130,HCPCS,Outpatient,,,80,48,,74.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,37.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.85,350,,,Fee Schedule,350% of CMS OPPS Rate,21.52,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,48.53,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,191,
OT GROUP,44509545,CDM,440,RC,97150,HCPCS,Outpatient,,,44,26.4,,60.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,30.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,350,,,Fee Schedule,350% of CMS OPPS Rate,17.38,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.19,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,191,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4470003,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4470003E,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4470003RT,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4470003RTE,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",4470004,CDM,401,RC,77066,HCPCS,Outpatient,,,320,192,,351.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,222.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,178.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.31,350,,,Fee Schedule,350% of CMS OPPS Rate,101.21,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,228.23,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,351.27,
BONE DENSITY FOREARM LEFT,4470006,CDM,320,RC,77081,HCPCS,Outpatient,,,143.55,86.13,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges,107.66,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,80.55,103,,,Fee Schedule,103% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.49,364,
BONE DENSITY FOREARM RIGHT,4470006RT,CDM,320,RC,77081,HCPCS,Outpatient,,,143.55,86.13,,279.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.49,70,,,percent of total billed charges,70% of total billed charges,107.66,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.44,350,,,Fee Schedule,350% of CMS OPPS Rate,80.55,103,,,Fee Schedule,103% of CMS OPPS Rate,109.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,64.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,86.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,100.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,68.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,129.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.49,364,
Scan to measure bone mineral density (BMD) at the spine and hip,4470008,CDM,320,RC,77080,HCPCS,Outpatient,,,303,181.8,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,364,
BX PROBE,4470011,CDM,271,RC,,,Outpatient,,,628.1,376.86,,113.06,18,,,percent of total billed charges,pays at 18% of total charges,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.05,50,,,percent of total billed charges,pays at 50% of total billed charges,439.67,70,,,percent of total billed charges,70% of total billed charges,471.08,75,,,percent of total billed charges,75% of total billed charges,314.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,502.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,376.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,480.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,439.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,376.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,238.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,439.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,628.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,565.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.42,628.1,
BX TUBING,4470022,CDM,271,RC,,,Outpatient,,,58.85,35.31,,10.59,18,,,percent of total billed charges,pays at 18% of total charges,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.59,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,29.43,50,,,percent of total billed charges,pays at 50% of total billed charges,41.2,70,,,percent of total billed charges,70% of total billed charges,44.14,75,,,percent of total billed charges,75% of total billed charges,29.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,47.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,58.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,52.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.22,58.85,
BX CLIP,4470033,CDM,278,RC,A4648,HCPCS,Outpatient,,,228.8,137.28,,41.18,18,,,percent of total billed charges,pays at 18% of total charges,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.16,70,,,percent of total billed charges,70% of total billed charges,171.6,75,,,percent of total billed charges,75% of total billed charges,114.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,228.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.94,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,228.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.85,228.8,
HAWRING III WIRE,4470044,CDM,272,RC,,,Outpatient,,,52.5,31.5,,9.45,18,,,percent of total billed charges,pays at 18% of total charges,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26.25,50,,,percent of total billed charges,pays at 50% of total billed charges,36.75,70,,,percent of total billed charges,70% of total billed charges,39.38,75,,,percent of total billed charges,75% of total billed charges,26.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,36.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,47.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.23,52.5,
Mammography of both breasts-2 or more views,4471000,CDM,403,RC,77067,HCPCS,Outpatient,,,307.34,184.4,,291.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,215.14,70,,,percent of total billed charges,70% of total billed charges,230.51,75,,,percent of total billed charges,75% of total billed charges,148.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.09,350,,,Fee Schedule,350% of CMS OPPS Rate,83.96,102,,,Fee Schedule,102% of CMS OPPS Rate,235.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,189.31,230,,,Fee Schedule,230% of CMS OPPS Rate,147.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,276.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,323,
Mammography of both breasts-2 or more views,4471001,CDM,403,RC,77067,HCPCS,Outpatient,,,307.34,184.4,,291.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,215.14,70,,,percent of total billed charges,70% of total billed charges,230.51,75,,,percent of total billed charges,75% of total billed charges,148.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.09,350,,,Fee Schedule,350% of CMS OPPS Rate,83.96,102,,,Fee Schedule,102% of CMS OPPS Rate,235.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,189.31,230,,,Fee Schedule,230% of CMS OPPS Rate,147.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,276.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,323,
Mammography of both breasts-2 or more views,4471001RT,CDM,403,RC,77067,HCPCS,Outpatient,,,307.34,184.4,,291.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,215.14,70,,,percent of total billed charges,70% of total billed charges,230.51,75,,,percent of total billed charges,75% of total billed charges,148.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.09,350,,,Fee Schedule,350% of CMS OPPS Rate,83.96,102,,,Fee Schedule,102% of CMS OPPS Rate,235.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,189.31,230,,,Fee Schedule,230% of CMS OPPS Rate,147.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,276.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",4472000,CDM,401,RC,77066,HCPCS,Outpatient,,,320,192,,351.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,222.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,178.61,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,347.31,350,,,Fee Schedule,350% of CMS OPPS Rate,101.21,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,228.23,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,351.27,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4472001,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4472001RT,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",4472001RTE,CDM,401,RC,77065,HCPCS,Outpatient,,,320,192,,275.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,224,70,,,percent of total billed charges,70% of total billed charges,240,75,,,percent of total billed charges,75% of total billed charges,140.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,256,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,272.51,350,,,Fee Schedule,350% of CMS OPPS Rate,79.42,102,,,Fee Schedule,102% of CMS OPPS Rate,244.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,144,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,192,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,224,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,179.08,230,,,Fee Schedule,230% of CMS OPPS Rate,153.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,288,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,77.86,100,,,Fee Schedule,100% of CMS OPPS Rate,50.14,323,
Mammography of both breasts-2 or more views,4472003,CDM,403,RC,77067,HCPCS,Outpatient,,,307.34,184.4,,291.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,215.14,70,,,percent of total billed charges,70% of total billed charges,230.51,75,,,percent of total billed charges,75% of total billed charges,148.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.09,350,,,Fee Schedule,350% of CMS OPPS Rate,83.96,102,,,Fee Schedule,102% of CMS OPPS Rate,235.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,138.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,215.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,189.31,230,,,Fee Schedule,230% of CMS OPPS Rate,147.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,276.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,82.31,100,,,Fee Schedule,100% of CMS OPPS Rate,48.16,323,
GALACTOGRAM-SINGLE LEFT,4476086,CDM,320,RC,77053,HCPCS,Outpatient,,,879.56,527.74,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,615.69,70,,,percent of total billed charges,70% of total billed charges,659.67,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,703.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,672.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,151.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,395.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,615.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,527.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,615.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,422.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,791.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,137.83,791.6,
GALACTOGRAM-SINGLE RIGHT,4476086RT,CDM,320,RC,77053,HCPCS,Outpatient,,,879.56,527.74,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,615.69,70,,,percent of total billed charges,70% of total billed charges,659.67,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,703.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,672.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,151.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,395.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,615.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,527.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,615.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,422.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,791.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,137.83,791.6,
GALACTOGRM SGL REDUCED SV,4476087,CDM,320,RC,77053,HCPCS,Outpatient,,,879.56,527.74,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,615.69,70,,,percent of total billed charges,70% of total billed charges,659.67,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,703.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,672.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,151.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,395.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,615.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,527.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,615.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,422.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,791.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,137.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,137.83,791.6,
GALACTOGRAM-MULTIPLE LEFT,4476088,CDM,320,RC,77054,HCPCS,Outpatient,,,732.4,439.44,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,512.68,70,,,percent of total billed charges,70% of total billed charges,549.3,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,585.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,560.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,329.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,512.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,512.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,351.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,659.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,114.77,751.51,
GALACTOGRAM-MULTIPLE RIGHT,4476088RT,CDM,320,RC,77054,HCPCS,Outpatient,,,732.4,439.44,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,512.68,70,,,percent of total billed charges,70% of total billed charges,549.3,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,585.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,560.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,126.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,329.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,512.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,439.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,512.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,351.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,659.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,114.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,114.77,751.51,
STEREO BREAST BIOPS LEFT EACH ADD LESION,4476092,CDM,320,RC,19082,HCPCS,Outpatient,,,1089,653.4,,196.02,18,,,percent of total billed charges,pays at 18% of total charges,1089,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,196.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.3,70,,,percent of total billed charges,70% of total billed charges,816.75,75,,,percent of total billed charges,75% of total billed charges,544.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,653.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,833.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,762.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,653.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,762.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1089,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,980.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.02,1089,
STEREO BREAST BIOPS RT EACH ADD LESION,4476092RT,CDM,320,RC,19082,HCPCS,Outpatient,,,1089,653.4,,196.02,18,,,percent of total billed charges,pays at 18% of total charges,1089,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,196.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.3,70,,,percent of total billed charges,70% of total billed charges,816.75,75,,,percent of total billed charges,75% of total billed charges,544.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,871.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,653.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,833.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,762.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,653.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,762.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1089,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,980.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1089,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.02,1089,
STEREOTACTIC BREAST BIOPS LEFT,4476093,CDM,320,RC,19081,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3715,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,4825.85,
STEREOTACTIC BREAST BIOPS RIGHT,4476093RT,CDM,320,RC,19081,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3715,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,4825.85,
MAMMO NEEDLE PLACEMENT,4476096,CDM,320,RC,19281,HCPCS,Outpatient,,,1651,990.6,,4825.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1651,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1155.7,70,,,percent of total billed charges,70% of total billed charges,1238.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1320.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.34,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1263.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,742.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,792.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,4825.87,
SURGICAL SPECIMEN,4476098,CDM,320,RC,76098,HCPCS,Outpatient,,,1304,782.4,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,992.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,912.8,70,,,percent of total billed charges,70% of total billed charges,978,75,,,percent of total billed charges,75% of total billed charges,823.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1043.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.88,350,,,Fee Schedule,350% of CMS OPPS Rate,466.54,103,,,Fee Schedule,103% of CMS OPPS Rate,997.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,224.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,586.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,912.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,782.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,912.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,625.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1173.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,204.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,204.34,1619.18,
MAMMO DIGITAL TOMO UNI LT,4477061,CDM,401,RC,77061,HCPCS,Outpatient,,,57,34.2,,10.26,18,,,percent of total billed charges,pays at 18% of total charges,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.9,70,,,percent of total billed charges,70% of total billed charges,42.75,75,,,percent of total billed charges,75% of total billed charges,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,Pays based on per visit ,39.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,323,
MAMMO DIGITAL TOMO UNI RT,4477061RT,CDM,401,RC,77061,HCPCS,Outpatient,,,57,34.2,,10.26,18,,,percent of total billed charges,pays at 18% of total charges,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.9,70,,,percent of total billed charges,70% of total billed charges,42.75,75,,,percent of total billed charges,75% of total billed charges,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,Pays based on per visit ,39.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,323,
MAMMO DIGITAL TOMO BILAT,4477062,CDM,401,RC,77062,HCPCS,Outpatient,,,57,34.2,,10.26,18,,,percent of total billed charges,pays at 18% of total charges,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.9,70,,,percent of total billed charges,70% of total billed charges,42.75,75,,,percent of total billed charges,75% of total billed charges,28.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,45.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,39.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,323,100,,,Case rate,Pays based on per visit ,39.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.93,323,
SCREENING MAMMO DIGITAL TOMO BILAT,4477063,CDM,403,RC,77063,HCPCS,Outpatient,,,67,40.2,,75.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,50.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,46.9,70,,,percent of total billed charges,70% of total billed charges,50.25,75,,,percent of total billed charges,75% of total billed charges,38.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.8,350,,,Fee Schedule,350% of CMS OPPS Rate,21.8,102,,,Fee Schedule,102% of CMS OPPS Rate,51.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,30.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,323,100,,,Case rate,Pays based on per visit ,46.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,49.15,230,,,Fee Schedule,230% of CMS OPPS Rate,32.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,21.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10.5,323,
INJECTION GALACTOGRAM,4479030,CDM,510,RC,19030,HCPCS,Outpatient,,,196,117.6,,35.28,18,,,percent of total billed charges,pays at 18% of total charges,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,75,,,percent of total billed charges,75% of total billed charges,98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,156.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,117.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,149.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,137.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,117.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,74.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,137.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,196,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,176.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.71,196,
BREAST BX,4479100,CDM,510,RC,19101,HCPCS,Outpatient,,,3243.2,1945.92,,11063.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3243.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2432.4,75,,,percent of total billed charges,75% of total billed charges,5625.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2594.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10938.56,350,,,Fee Schedule,350% of CMS OPPS Rate,3187.8,103,,,Fee Schedule,103% of CMS OPPS Rate,2481.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1459.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2270.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1945.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2270.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1556.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2918.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3243.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.42,11063.57,
STEREOTAT GD BRST BX REDU,4479102,CDM,320,RC,19081,HCPCS,Outpatient,,,1364.88,818.93,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1364.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,955.42,70,,,percent of total billed charges,70% of total billed charges,1023.66,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1091.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1364.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1044.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,614.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,955.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,818.93,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,955.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,655.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1228.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1364.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,364,4825.85,
REMOVAL OF BREAST LESION,4479120,CDM,360,RC,19120,HCPCS,Outpatient,,,5467,3280.2,,11063.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5450.55,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3826.9,70,,,percent of total billed charges,70% of total billed charges,4100.25,75,,,percent of total billed charges,75% of total billed charges,5625.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10938.56,350,,,Fee Schedule,350% of CMS OPPS Rate,3187.8,103,,,Fee Schedule,103% of CMS OPPS Rate,4182.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2460.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3826.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3280.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3826.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2624.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4920.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,11063.57,
PL NDL LOCALIZE WIRE INIT,4479290,CDM,360,RC,19281,HCPCS,Outpatient,,,357,214.2,,4825.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,357,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,249.9,70,,,percent of total billed charges,70% of total billed charges,267.75,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.34,350,,,Fee Schedule,350% of CMS OPPS Rate,357,103,,,Fee Schedule,103% of CMS OPPS Rate,273.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,171.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,357,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,4825.87,
NEEDLE HAWKINS III-3,4479291,CDM,272,RC,,,Outpatient,,,81.45,48.87,,14.66,18,,,percent of total billed charges,pays at 18% of total charges,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,50,,,percent of total billed charges,pays at 50% of total billed charges,57.02,70,,,percent of total billed charges,70% of total billed charges,61.09,75,,,percent of total billed charges,75% of total billed charges,40.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,81.45,
NEEDLE HAWKINS III-5,4479292,CDM,272,RC,,,Outpatient,,,90.5,54.3,,16.29,18,,,percent of total billed charges,pays at 18% of total charges,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.29,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,45.25,50,,,percent of total billed charges,pays at 50% of total billed charges,63.35,70,,,percent of total billed charges,70% of total billed charges,67.88,75,,,percent of total billed charges,75% of total billed charges,45.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,72.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,63.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,90.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,81.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.18,90.5,
NEEDLE HAWKINS III-7.5,4479293,CDM,272,RC,,,Outpatient,,,81.45,48.87,,14.66,18,,,percent of total billed charges,pays at 18% of total charges,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.66,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.73,50,,,percent of total billed charges,pays at 50% of total billed charges,57.02,70,,,percent of total billed charges,70% of total billed charges,61.09,75,,,percent of total billed charges,75% of total billed charges,40.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,65.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,57.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,73.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,81.45,
GALACTOGRAPHY INFUSION K,4479294,CDM,272,RC,,,Outpatient,,,79.75,47.85,,14.36,18,,,percent of total billed charges,pays at 18% of total charges,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.88,50,,,percent of total billed charges,pays at 50% of total billed charges,55.83,70,,,percent of total billed charges,70% of total billed charges,59.81,75,,,percent of total billed charges,75% of total billed charges,39.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,63.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.89,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.31,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,79.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,71.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.5,79.75,
PL NL LOCALZ WIRE EA ADDL,4479296,CDM,510,RC,19282,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
FEES SWALLOW EVAL,449930,CDM,444,RC,92612,HCPCS,Outpatient,,,162,97.2,,227.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,154.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,141.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,115.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.26,350,,,Fee Schedule,350% of CMS OPPS Rate,65.65,102,,,Fee Schedule,102% of CMS OPPS Rate,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148.03,230,,,Fee Schedule,230% of CMS OPPS Rate,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,227.83,
PT EVAL LOW COMPLEXITY,4500025,CDM,424,RC,97161,HCPCS,Outpatient,,,79,47.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.3,70,,,percent of total billed charges,70% of total billed charges,59.25,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,60.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,71.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,35.55,339.42,
PT EVAL MOD COMP 30MIN,4500028,CDM,424,RC,97162,HCPCS,Outpatient,,,109,65.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.3,70,,,percent of total billed charges,70% of total billed charges,81.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,87.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,83.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,76.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,52.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,98.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.05,339.42,
PT EVALHIGH COMP 45MIN,4500030,CDM,424,RC,97163,HCPCS,Outpatient,,,158.36,95.02,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.85,70,,,percent of total billed charges,70% of total billed charges,118.77,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,121.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,110.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,76.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,142.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,339.42,
A technique used by physical therapists to restore normal body movement patterns,4500040,CDM,420,RC,97112,HCPCS,Outpatient,,,67.28,40.37,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.1,70,,,percent of total billed charges,70% of total billed charges,50.46,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,51.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,47.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,32.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,191,
PROSTHETIC TRAIN INT 15MN,4500050,CDM,420,RC,97761,HCPCS,Outpatient,,,98.4,59.04,,139.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,39.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.88,70,,,percent of total billed charges,70% of total billed charges,73.8,75,,,percent of total billed charges,75% of total billed charges,70.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.52,350,,,Fee Schedule,350% of CMS OPPS Rate,40.08,102,,,Fee Schedule,102% of CMS OPPS Rate,75.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,44.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,90.37,230,,,Fee Schedule,230% of CMS OPPS Rate,47.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,88.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,19.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,39.29,100,,,Fee Schedule,100% of CMS OPPS Rate,19.99,191,
A type of physical therapy,4500060,CDM,420,RC,97116,HCPCS,Outpatient,,,85.86,51.52,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.1,70,,,percent of total billed charges,70% of total billed charges,64.4,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,65.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,41.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,77.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.45,191,
WHEELCHAIR MOB TRN 15 MIN,4500061,CDM,420,RC,97542,HCPCS,Outpatient,,,83.43,50.06,,107.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,69.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.4,70,,,percent of total billed charges,70% of total billed charges,62.57,75,,,percent of total billed charges,75% of total billed charges,54.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.05,350,,,Fee Schedule,350% of CMS OPPS Rate,30.91,102,,,Fee Schedule,102% of CMS OPPS Rate,63.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,37.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.69,230,,,Fee Schedule,230% of CMS OPPS Rate,40.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.07,191,
PT HOME EVALUATION,4500077,CDM,424,RC,97163,HCPCS,Outpatient,,,158.36,95.02,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.85,70,,,percent of total billed charges,70% of total billed charges,118.77,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,121.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,110.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,76.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,142.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,339.42,
CANALITH REPOSITIONING,4500080,CDM,420,RC,95992,HCPCS,Outpatient,,,84.8,50.88,,124.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.36,70,,,percent of total billed charges,70% of total billed charges,63.6,75,,,percent of total billed charges,75% of total billed charges,63.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,67.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.45,350,,,Fee Schedule,350% of CMS OPPS Rate,35.98,102,,,Fee Schedule,102% of CMS OPPS Rate,64.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,38.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,59.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,81.12,230,,,Fee Schedule,230% of CMS OPPS Rate,40.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,76.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.29,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.29,191,
GROUP THERAPEUTIC PROC OT,4500088,CDM,430,RC,97150,HCPCS,Outpatient,,,60.3,36.18,,60.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42.21,70,,,percent of total billed charges,70% of total billed charges,45.23,75,,,percent of total billed charges,75% of total billed charges,30.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,350,,,Fee Schedule,350% of CMS OPPS Rate,17.38,102,,,Fee Schedule,102% of CMS OPPS Rate,46.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,27.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,42.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.19,230,,,Fee Schedule,230% of CMS OPPS Rate,28.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,54.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,9.45,191,
GROUP THERAPEUTIC PROC PT,4500089,CDM,420,RC,97150,HCPCS,Outpatient,,,60.3,36.18,,60.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42.21,70,,,percent of total billed charges,70% of total billed charges,45.23,75,,,percent of total billed charges,75% of total billed charges,30.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,350,,,Fee Schedule,350% of CMS OPPS Rate,17.38,102,,,Fee Schedule,102% of CMS OPPS Rate,46.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,27.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,42.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.19,230,,,Fee Schedule,230% of CMS OPPS Rate,28.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,54.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,9.45,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4500090,CDM,421,RC,97110,HCPCS,Outpatient,,,90.63,54.38,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.44,70,,,percent of total billed charges,70% of total billed charges,67.97,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,69.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,43.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,81.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
Occupational therapy,4500091,CDM,420,RC,97535,HCPCS,Outpatient,,,92.75,55.65,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.93,70,,,percent of total billed charges,70% of total billed charges,69.56,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,70.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,41.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,44.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,191,
PT RE EVALUATION,4500092,CDM,424,RC,97164,HCPCS,Outpatient,,,107,64.2,,234.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.9,70,,,percent of total billed charges,70% of total billed charges,80.25,75,,,percent of total billed charges,75% of total billed charges,119.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.49,350,,,Fee Schedule,350% of CMS OPPS Rate,67.46,102,,,Fee Schedule,102% of CMS OPPS Rate,81.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,48.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,152.12,230,,,Fee Schedule,230% of CMS OPPS Rate,51.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,96.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,48.15,234.14,
CKOUT PROS/ORTH USE 15MIN,4500093,CDM,420,RC,97763,HCPCS,Outpatient,,,99,59.4,,174.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,49.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.5,50,,,percent of total billed charges,pays at 50% of total billed charges,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,88.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,172.55,350,,,Fee Schedule,350% of CMS OPPS Rate,50.29,102,,,Fee Schedule,102% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,113.39,230,,,Fee Schedule,230% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,39.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,49.3,100,,,Fee Schedule,100% of CMS OPPS Rate,39.32,191,
PHYS PERF TEST/MEAS 15 MN,4500094,CDM,420,RC,97750,HCPCS,Outpatient,,,114.12,68.47,,113.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.88,70,,,percent of total billed charges,70% of total billed charges,85.59,75,,,percent of total billed charges,75% of total billed charges,57.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,91.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.86,350,,,Fee Schedule,350% of CMS OPPS Rate,32.6,102,,,Fee Schedule,102% of CMS OPPS Rate,87.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,51.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,79.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,73.51,230,,,Fee Schedule,230% of CMS OPPS Rate,54.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,102.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,17.88,191,
Occupational therapy,4500095,CDM,420,RC,97535,HCPCS,Outpatient,,,86.85,52.11,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges,65.14,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,66.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,41.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,191,
Use of massage,4500096,CDM,420,RC,97124,HCPCS,Outpatient,,,82,49.2,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,191,
Manipulation of 1 or more regions of the body,4500097,CDM,420,RC,97140,HCPCS,Outpatient,,,74.12,44.47,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.88,70,,,percent of total billed charges,70% of total billed charges,55.59,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,56.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,35.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,66.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,191,
TEAM CONF W/PAT-PT,4500098,CDM,940,RC,99366,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
TEAM CONF W/O PAT-PT,4500099,CDM,940,RC,99368,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
COGNITIVE PERCEP ACT OT INIT 15MN,4500131,CDM,434,RC,97129,HCPCS,Outpatient,,,85.86,51.52,,77.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.93,50,,,percent of total billed charges,pays at 50% of total billed charges,60.1,70,,,percent of total billed charges,70% of total billed charges,64.4,75,,,percent of total billed charges,75% of total billed charges,39.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.22,102,,,Fee Schedule,102% of CMS OPPS Rate,65.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,230,,,Fee Schedule,230% of CMS OPPS Rate,41.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,77.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.45,191,
COGNITIVE PERCEP ACT OT ADD 15M,4500132,CDM,434,RC,97130,HCPCS,Outpatient,,,80,48,,74.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,37.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.85,350,,,Fee Schedule,350% of CMS OPPS Rate,21.52,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,48.53,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,191,
Occupational therapy,4500147,CDM,430,RC,97535,HCPCS,Outpatient,,,86.85,52.11,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.8,70,,,percent of total billed charges,70% of total billed charges,65.14,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,66.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,41.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,13.61,191,
WHLCHR MOB TRAIN-OT-15MIN,4500151,CDM,430,RC,97542,HCPCS,Outpatient,,,83.43,50.06,,107.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,69.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.4,70,,,percent of total billed charges,70% of total billed charges,62.57,75,,,percent of total billed charges,75% of total billed charges,54.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.05,350,,,Fee Schedule,350% of CMS OPPS Rate,30.91,102,,,Fee Schedule,102% of CMS OPPS Rate,63.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,37.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.69,230,,,Fee Schedule,230% of CMS OPPS Rate,40.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.07,191,
COMM/WORK REINTEGR-15M OT,4500158,CDM,430,RC,97537,HCPCS,Outpatient,,,83.43,50.06,,107.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.4,70,,,percent of total billed charges,70% of total billed charges,62.57,75,,,percent of total billed charges,75% of total billed charges,54.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.05,350,,,Fee Schedule,350% of CMS OPPS Rate,30.91,102,,,Fee Schedule,102% of CMS OPPS Rate,63.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,37.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.69,230,,,Fee Schedule,230% of CMS OPPS Rate,40.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.07,191,
A technique used by physical therapists to restore normal body movement patterns,4500165,CDM,430,RC,97112,HCPCS,Outpatient,,,67.28,40.37,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.1,70,,,percent of total billed charges,70% of total billed charges,50.46,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,53.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,51.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.59,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,47.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,32.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,10.54,191,
Manipulation of 1 or more regions of the body,4500166,CDM,430,RC,97140,HCPCS,Outpatient,,,74.12,44.47,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,51.88,70,,,percent of total billed charges,70% of total billed charges,55.59,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,59.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,56.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,44.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,51.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,35.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,66.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,11.61,191,
Use of massage,4500167,CDM,430,RC,97124,HCPCS,Outpatient,,,82,49.2,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.4,70,,,percent of total billed charges,70% of total billed charges,61.5,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,62.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,36.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,57.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,39.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,12.85,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4500170,CDM,430,RC,97110,HCPCS,Outpatient,,,90.63,54.38,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.44,70,,,percent of total billed charges,70% of total billed charges,67.97,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,69.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,63.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,43.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,81.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",4500171,CDM,430,RC,97530,HCPCS,Outpatient,,,100.44,60.26,,123.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,70.31,70,,,percent of total billed charges,70% of total billed charges,75.33,75,,,percent of total billed charges,75% of total billed charges,62.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.12,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,76.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,45.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,70.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,80.25,230,,,Fee Schedule,230% of CMS OPPS Rate,48.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,191,
CONTRAST BATH 15 MIN - OT,4500172,CDM,430,RC,97034,HCPCS,Outpatient,,,62.37,37.42,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,191,
OT HOME EVAL,4500177,CDM,434,RC,97167,HCPCS,Outpatient,,,184.68,110.81,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.28,70,,,percent of total billed charges,70% of total billed charges,138.51,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,141.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,83.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,129.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,88.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,166.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
Occupational therapy,4500187,CDM,430,RC,97535,HCPCS,Outpatient,,,92.75,55.65,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.93,70,,,percent of total billed charges,70% of total billed charges,69.56,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,70.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,41.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,44.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,191,
Repeated application to one or more parts of the body,4500190,CDM,430,RC,97032,HCPCS,Outpatient,,,69.3,41.58,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.51,70,,,percent of total billed charges,70% of total billed charges,51.98,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,53.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,48.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,33.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.86,191,
OT RE EVALUATION,4500192,CDM,434,RC,97168,HCPCS,Outpatient,,,111,66.6,,233.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.7,70,,,percent of total billed charges,70% of total billed charges,83.25,75,,,percent of total billed charges,75% of total billed charges,118.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.44,350,,,Fee Schedule,350% of CMS OPPS Rate,67.16,102,,,Fee Schedule,102% of CMS OPPS Rate,84.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,49.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,151.43,230,,,Fee Schedule,230% of CMS OPPS Rate,53.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.58,233.07,
TEAM CONF W/PAT-OT,4500193,CDM,940,RC,99366,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
TEAM CONF W/O PAT-OT,4500194,CDM,940,RC,99368,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
ELECTRIC STIM - OT,4500199,CDM,430,RC,G0283,HCPCS,Outpatient,,,62.37,37.42,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,191,
COGNITIVE TESTING PER HR,4500201,CDM,440,RC,96125,HCPCS,Outpatient,,,187.2,112.32,,347.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,244.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges,140.4,75,,,percent of total billed charges,75% of total billed charges,176.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.77,350,,,Fee Schedule,350% of CMS OPPS Rate,100.18,102,,,Fee Schedule,102% of CMS OPPS Rate,143.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,225.91,230,,,Fee Schedule,230% of CMS OPPS Rate,89.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,168.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.33,347.7,
VOICE/ RESONANCE EVAL,4500204,CDM,444,RC,92524,HCPCS,Outpatient,,,162.41,97.45,,374.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.69,70,,,percent of total billed charges,70% of total billed charges,121.81,75,,,percent of total billed charges,75% of total billed charges,190.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.2,350,,,Fee Schedule,350% of CMS OPPS Rate,107.89,102,,,Fee Schedule,102% of CMS OPPS Rate,124.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,243.27,230,,,Fee Schedule,230% of CMS OPPS Rate,77.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,146.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,374.43,
Evaluation of speech sound production with evaluation of language comprehension,4500206,CDM,444,RC,92523,HCPCS,Outpatient,,,400,240,,773.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,407.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,393.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765.1,350,,,Fee Schedule,350% of CMS OPPS Rate,222.97,102,,,Fee Schedule,102% of CMS OPPS Rate,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,502.78,230,,,Fee Schedule,230% of CMS OPPS Rate,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,773.84,
TEAM CONF W/PAT-SLP,4500207,CDM,940,RC,99366,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
TEAM CONF W/O PAT-SLP,4500208,CDM,940,RC,99368,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
BEDSIDE SWALLOW EVAL-ST,4500221,CDM,444,RC,92610,HCPCS,Outpatient,,,220,132,,239.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,121.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.5,350,,,Fee Schedule,350% of CMS OPPS Rate,68.92,102,,,Fee Schedule,102% of CMS OPPS Rate,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,155.41,230,,,Fee Schedule,230% of CMS OPPS Rate,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,37.16,239.2,
VIDEO SWALLOW EXAM,4500222,CDM,440,RC,92611,HCPCS,Outpatient,,,357,214.2,,309.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,87.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,180.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.9,70,,,percent of total billed charges,70% of total billed charges,267.75,75,,,percent of total billed charges,75% of total billed charges,157.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.87,350,,,Fee Schedule,350% of CMS OPPS Rate,89.14,102,,,Fee Schedule,102% of CMS OPPS Rate,273.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,201,230,,,Fee Schedule,230% of CMS OPPS Rate,171.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.36,321.3,
FEES SWALLOW EVAL,4500223,CDM,444,RC,92612,HCPCS,Outpatient,,,162,97.2,,227.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,154.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,141.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,115.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.26,350,,,Fee Schedule,350% of CMS OPPS Rate,65.65,102,,,Fee Schedule,102% of CMS OPPS Rate,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148.03,230,,,Fee Schedule,230% of CMS OPPS Rate,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,227.83,
ASSESSMENT OF APHASIA X60,4500224,CDM,440,RC,96105,HCPCS,Outpatient,,,122,73.2,,333.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,223.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.4,70,,,percent of total billed charges,70% of total billed charges,91.5,75,,,percent of total billed charges,75% of total billed charges,169.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,97.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,330.19,350,,,Fee Schedule,350% of CMS OPPS Rate,96.23,102,,,Fee Schedule,102% of CMS OPPS Rate,93.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,54.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,85.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,216.98,230,,,Fee Schedule,230% of CMS OPPS Rate,58.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,109.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,94.34,100,,,Fee Schedule,100% of CMS OPPS Rate,19.12,333.96,
COGNITIVE RETRAINING ST INIT 15M,4500228,CDM,440,RC,97129,HCPCS,Outpatient,,,85.86,51.52,,77.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.93,50,,,percent of total billed charges,pays at 50% of total billed charges,60.1,70,,,percent of total billed charges,70% of total billed charges,64.4,75,,,percent of total billed charges,75% of total billed charges,39.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.22,102,,,Fee Schedule,102% of CMS OPPS Rate,65.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,38.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,230,,,Fee Schedule,230% of CMS OPPS Rate,41.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,77.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.45,191,
COGNITIVE RETRAIN ST ADD 15M,4500229,CDM,440,RC,97130,HCPCS,Outpatient,,,80,48,,74.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,37.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.85,350,,,Fee Schedule,350% of CMS OPPS Rate,21.52,102,,,Fee Schedule,102% of CMS OPPS Rate,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,48.53,230,,,Fee Schedule,230% of CMS OPPS Rate,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,12.54,191,
Therapy for speech or hearing,4500230,CDM,440,RC,92507,HCPCS,Outpatient,,,293,175.8,,260.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.1,70,,,percent of total billed charges,70% of total billed charges,219.75,75,,,percent of total billed charges,75% of total billed charges,132.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.25,350,,,Fee Schedule,350% of CMS OPPS Rate,74.97,102,,,Fee Schedule,102% of CMS OPPS Rate,224.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,131.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.05,230,,,Fee Schedule,230% of CMS OPPS Rate,140.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,263.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.56,263.7,
AUDIOMETRIC SCREENING,4500240,CDM,470,RC,92551,HCPCS,Outpatient,,,87.75,52.65,,15.8,18,,,percent of total billed charges,pays at 18% of total charges,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,43.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,100,,,Case rate,Pays based on per visit ,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,137,
SPLINT FAB 15 MIN,4500242,CDM,430,RC,97760,HCPCS,Outpatient,,,149.04,89.42,,160.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.33,70,,,percent of total billed charges,70% of total billed charges,111.78,75,,,percent of total billed charges,75% of total billed charges,81.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.31,350,,,Fee Schedule,350% of CMS OPPS Rate,46.13,102,,,Fee Schedule,102% of CMS OPPS Rate,114.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,67.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,104.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,104.03,230,,,Fee Schedule,230% of CMS OPPS Rate,71.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,134.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,191,
OT EVAL LOW COMPLEXITY,4500245,CDM,434,RC,97165,HCPCS,Outpatient,,,92,55.2,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.4,70,,,percent of total billed charges,70% of total billed charges,69,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,73.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,70.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,41.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,64.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,44.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,82.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,41.4,339.42,
OT EVAL MOD COMP 45MIN,4500248,CDM,434,RC,97166,HCPCS,Outpatient,,,111,66.6,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.7,70,,,percent of total billed charges,70% of total billed charges,83.25,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,88.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,84.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,77.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,53.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.95,339.42,
OT EVAL HIGH COMP 60MIN,4500250,CDM,434,RC,97167,HCPCS,Outpatient,,,184.68,110.81,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,129.28,70,,,percent of total billed charges,70% of total billed charges,138.51,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,147.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,141.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,83.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,129.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,88.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,166.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
COMM/WORK REINTER-15MN-ST,4500251,CDM,440,RC,97537,HCPCS,Outpatient,,,83.43,50.06,,107.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.4,70,,,percent of total billed charges,70% of total billed charges,62.57,75,,,percent of total billed charges,75% of total billed charges,54.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.05,350,,,Fee Schedule,350% of CMS OPPS Rate,30.91,102,,,Fee Schedule,102% of CMS OPPS Rate,63.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,37.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.69,230,,,Fee Schedule,230% of CMS OPPS Rate,40.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.07,191,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",4500260,CDM,420,RC,97035,HCPCS,Outpatient,,,55.44,33.26,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.81,70,,,percent of total billed charges,70% of total billed charges,41.58,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,42.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,24.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,38.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,26.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,49.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,8.69,191,
DYSPHAGIA TREATMENT,4500266,CDM,440,RC,92526,HCPCS,Outpatient,,,211,126.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,147.7,70,,,percent of total billed charges,70% of total billed charges,158.25,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,168.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,161.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,94.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,101.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,189.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,33.06,287.06,
ELECTRIC STIM,4500270,CDM,420,RC,G0283,HCPCS,Outpatient,,,62.37,37.42,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,191,
Repeated application to one or more parts of the body,4500271,CDM,420,RC,97032,HCPCS,Outpatient,,,69.3,41.58,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.51,70,,,percent of total billed charges,70% of total billed charges,51.98,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,53.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,48.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,33.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,62.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,10.86,191,
HAND FINGER ORTHOTIC STATIC,4500411,CDM,274,RC,L3923,HCPCS,Outpatient,,,126,75.6,,323.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63,50,,,percent of total billed charges,pays at 50% of total billed charges,88.2,70,,,percent of total billed charges,70% of total billed charges,94.5,75,,,percent of total billed charges,75% of total billed charges,164.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,319.45,350,,,Fee Schedule,350% of CMS OPPS Rate,93.1,102,,,Fee Schedule,102% of CMS OPPS Rate,126,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,56.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,47.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,126,230,,,Fee Schedule,230% of CMS OPPS Rate,60.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,100% of CMS OPPS Rate,126,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,91.27,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,19.74,323.1,
ANTISPACTICITY SPLINT,4500413,CDM,270,RC,L3807,HCPCS,Outpatient,,,145,87,,928.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,72.5,50,,,percent of total billed charges,pays at 50% of total billed charges,101.5,70,,,percent of total billed charges,70% of total billed charges,108.75,75,,,percent of total billed charges,75% of total billed charges,472.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,116,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.33,350,,,Fee Schedule,350% of CMS OPPS Rate,267.63,102,,,Fee Schedule,102% of CMS OPPS Rate,110.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,65.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,101.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,55.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,101.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,145,230,,,Fee Schedule,230% of CMS OPPS Rate,69.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,100% of CMS OPPS Rate,130.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,22.72,928.83,
FUNCTIONAL HAND SPLINT,4500414,CDM,270,RC,L3807,HCPCS,Outpatient,,,136.5,81.9,,928.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,262.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.25,50,,,percent of total billed charges,pays at 50% of total billed charges,95.55,70,,,percent of total billed charges,70% of total billed charges,102.38,75,,,percent of total billed charges,75% of total billed charges,472.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,918.33,350,,,Fee Schedule,350% of CMS OPPS Rate,267.63,102,,,Fee Schedule,102% of CMS OPPS Rate,104.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,61.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,51.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,136.5,230,,,Fee Schedule,230% of CMS OPPS Rate,65.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,262.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,21.39,928.83,
WRIST COCK-UP SPLINT,4500415,CDM,270,RC,,,Outpatient,,,117.5,70.5,,21.15,18,,,percent of total billed charges,pays at 18% of total charges,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.15,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,58.75,50,,,percent of total billed charges,pays at 50% of total billed charges,82.25,70,,,percent of total billed charges,70% of total billed charges,88.13,75,,,percent of total billed charges,75% of total billed charges,58.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.41,117.5,
ORTHOIC MGMT/ TR 15 MN-OT,4500422,CDM,430,RC,97760,HCPCS,Outpatient,,,98.4,59.04,,160.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.88,70,,,percent of total billed charges,70% of total billed charges,73.8,75,,,percent of total billed charges,75% of total billed charges,81.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.31,350,,,Fee Schedule,350% of CMS OPPS Rate,46.13,102,,,Fee Schedule,102% of CMS OPPS Rate,75.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,44.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,104.03,230,,,Fee Schedule,230% of CMS OPPS Rate,47.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,88.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,191,
Occupational therapy,4500423,CDM,430,RC,97535,HCPCS,Outpatient,,,92.75,55.65,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,64.93,70,,,percent of total billed charges,70% of total billed charges,69.56,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,74.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,70.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,41.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,64.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,44.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.53,191,
ASSESS/REASS HLTH/BEHAV 60MIN,4500800,CDM,914,RC,96156,HCPCS,Outpatient,,,179.22,107.53,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.61,50,,,percent of total billed charges,pays at 50% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,143.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,137.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,80.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,86.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,161.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,244.09,
ASSESS/REASS HLTH/BEHAV 120M,4500801,CDM,914,RC,96156,HCPCS,Outpatient,,,199.22,119.53,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.61,50,,,percent of total billed charges,pays at 50% of total billed charges,149.42,75,,,percent of total billed charges,75% of total billed charges,149.42,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,159.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,152.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,89.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,139.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,95.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,179.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,244.09,
INTERV HLTH/BEHAV INIT 30M,4500802,CDM,914,RC,96158,HCPCS,Outpatient,,,179.22,107.53,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.61,50,,,percent of total billed charges,pays at 50% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,143.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,137.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,80.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,86.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,161.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,244.09,
"INTERV HLTH/BEH,GROUP 30M",4500803,CDM,914,RC,96164,HCPCS,Outpatient,,,62.35,37.41,,95.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.18,50,,,percent of total billed charges,pays at 50% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,48.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.43,350,,,Fee Schedule,350% of CMS OPPS Rate,27.51,103,,,Fee Schedule,103% of CMS OPPS Rate,47.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,95.51,
"INTERV HLTH/BEH,FAMW/PT INIT30M",4500804,CDM,916,RC,96167,HCPCS,Outpatient,,,62.35,37.41,,95.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.18,50,,,percent of total billed charges,pays at 50% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,48.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.43,350,,,Fee Schedule,350% of CMS OPPS Rate,27.51,103,,,Fee Schedule,103% of CMS OPPS Rate,47.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,95.51,
"INTERV HLT/BEH,FAMW/OPT 30M",4500805,CDM,916,RC,96170,HCPCS,Outpatient,,,52,31.2,,9.36,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,9.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26,50,,,percent of total billed charges,pays at 50% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,52,
TEAM CONF W/PAT-SW,4500806,CDM,940,RC,99366,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
TEAM CONF W/O PAT-SW,4500807,CDM,940,RC,99368,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
INTERV HLTH/BEHAVE ADD 15M,4500822,CDM,914,RC,96159,HCPCS,Outpatient,,,57.63,34.58,,10.37,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,10.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.82,50,,,percent of total billed charges,pays at 50% of total billed charges,43.22,75,,,percent of total billed charges,75% of total billed charges,43.22,75,,,percent of total billed charges,75% of total billed charges,28.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57.63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,57.63,
"INTER HLTH/BEH, GROUP ADD 15M",4500823,CDM,914,RC,96165,HCPCS,Outpatient,,,11.23,6.74,,2.02,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,2.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.62,50,,,percent of total billed charges,pays at 50% of total billed charges,8.42,75,,,percent of total billed charges,75% of total billed charges,8.42,75,,,percent of total billed charges,75% of total billed charges,5.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,8.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,10.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.02,11.23,
"INTER HLTH/BEH, FAMW/PT ADD 15M",4500824,CDM,916,RC,96168,HCPCS,Outpatient,,,62.83,37.7,,11.31,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,11.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.42,50,,,percent of total billed charges,pays at 50% of total billed charges,47.12,75,,,percent of total billed charges,75% of total billed charges,47.12,75,,,percent of total billed charges,75% of total billed charges,31.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.31,62.83,
"INTERV HLTH/BEH, FAMW/OPT ADD 15M",4500825,CDM,916,RC,96171,HCPCS,Outpatient,,,52,31.2,,9.36,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,9.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26,50,,,percent of total billed charges,pays at 50% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,52,
Therapy for speech or hearing,4501288,CDM,440,RC,92507,HCPCS,Outpatient,,,293,175.8,,260.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.1,70,,,percent of total billed charges,70% of total billed charges,219.75,75,,,percent of total billed charges,75% of total billed charges,132.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.25,350,,,Fee Schedule,350% of CMS OPPS Rate,74.97,102,,,Fee Schedule,102% of CMS OPPS Rate,224.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,131.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.05,230,,,Fee Schedule,230% of CMS OPPS Rate,140.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,263.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.56,263.7,
COMM/WORK REINTER-15MN-PT,4506010,CDM,420,RC,97537,HCPCS,Outpatient,,,83.43,50.06,,107.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.4,70,,,percent of total billed charges,70% of total billed charges,62.57,75,,,percent of total billed charges,75% of total billed charges,54.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.05,350,,,Fee Schedule,350% of CMS OPPS Rate,30.91,102,,,Fee Schedule,102% of CMS OPPS Rate,63.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,37.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.69,230,,,Fee Schedule,230% of CMS OPPS Rate,40.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,75.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,13.07,191,
MH HEALTH/BEH ASSESS OR RE-ASS 60M,4507015,CDM,914,RC,96156,HCPCS,Outpatient,,,179.22,107.53,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.61,50,,,percent of total billed charges,pays at 50% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,143.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,137.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,80.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,86.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,161.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,244.09,
MH HEALTH/BEH ASSESS OR RE-ASS 120M,4507016,CDM,914,RC,96156,HCPCS,Outpatient,,,199.22,119.53,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.61,50,,,percent of total billed charges,pays at 50% of total billed charges,149.42,75,,,percent of total billed charges,75% of total billed charges,149.42,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,159.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,152.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,89.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,139.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,119.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,139.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,95.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,179.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,244.09,
MH HLTH/BEH INTERV INI 30M,4507017,CDM,914,RC,96158,HCPCS,Outpatient,,,179.22,107.53,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,89.61,50,,,percent of total billed charges,pays at 50% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,134.42,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,143.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,137.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,80.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,125.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,86.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,161.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,244.09,
MH HLTH/BEH GROUP INI 30M,4507018,CDM,915,RC,96164,HCPCS,Outpatient,,,62.35,37.41,,95.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.18,50,,,percent of total billed charges,pays at 50% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,48.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.43,350,,,Fee Schedule,350% of CMS OPPS Rate,27.51,103,,,Fee Schedule,103% of CMS OPPS Rate,47.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,95.51,
MH HLTH/BEH FLY W/PT INI 30M,4507019,CDM,916,RC,96167,HCPCS,Outpatient,,,62.35,37.41,,95.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,26.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.18,50,,,percent of total billed charges,pays at 50% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,46.76,75,,,percent of total billed charges,75% of total billed charges,48.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.43,350,,,Fee Schedule,350% of CMS OPPS Rate,27.51,103,,,Fee Schedule,103% of CMS OPPS Rate,47.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,100,,,Fee Schedule,100% of CMS OPPS Rate,26.98,95.51,
MH HLTH/BEH FLY W/O PT INI 30M,4507020,CDM,916,RC,96170,HCPCS,Outpatient,,,52,31.2,,9.36,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,9.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26,50,,,percent of total billed charges,pays at 50% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,52,
REHAB SKINTEMP BIO TRN,4507023,CDM,420,RC,90901,HCPCS,Outpatient,,,98.1,58.86,,65.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.67,70,,,percent of total billed charges,70% of total billed charges,73.58,75,,,percent of total billed charges,75% of total billed charges,33.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.51,350,,,Fee Schedule,350% of CMS OPPS Rate,18.8,102,,,Fee Schedule,102% of CMS OPPS Rate,75.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,42.39,230,,,Fee Schedule,230% of CMS OPPS Rate,47.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,18.43,100,,,Fee Schedule,100% of CMS OPPS Rate,15.37,191,
RESULTS EXPLAINED TO FMLY,4507025,CDM,919,RC,90887,HCPCS,Outpatient,,,30.4,18.24,,5.47,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,5.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.8,75,,,percent of total billed charges,75% of total billed charges,22.8,75,,,percent of total billed charges,75% of total billed charges,15.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,24.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,21.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,21.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,27.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.47,30.4,
NEUROBEHAVIORAL EXAM,4507026,CDM,918,RC,96116,HCPCS,Outpatient,,,322,193.2,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,241.5,75,,,percent of total billed charges,75% of total billed charges,241.5,75,,,percent of total billed charges,75% of total billed charges,268.22,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,257.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,246.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,144.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,225.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,225.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,154.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,289.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,144.9,507.34,
Group psychotherapy,4507027,CDM,915,RC,90853,HCPCS,Outpatient,,,79,47.4,,244.09,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,146.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.25,75,,,percent of total billed charges,75% of total billed charges,59.25,75,,,percent of total billed charges,75% of total billed charges,124.11,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.33,350,,,Fee Schedule,350% of CMS OPPS Rate,70.31,103,,,Fee Schedule,103% of CMS OPPS Rate,60.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,158.59,100,,,Fee Schedule,100% of CMS OPPS Rate,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,71.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,68.94,100,,,Fee Schedule,100% of CMS OPPS Rate,35.55,244.09,
"Psychotherapy, 30 min",4507028,CDM,914,RC,90832,HCPCS,Outpatient,,,130.7,78.42,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,130.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.03,75,,,percent of total billed charges,75% of total billed charges,98.03,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,130.7,103,,,Fee Schedule,103% of CMS OPPS Rate,99.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,58.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,91.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,62.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,130.7,100,,,Fee Schedule,100% of CMS OPPS Rate,117.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,58.82,268.22,
"Family psychotherapy, including patient, 50 min",4507029,CDM,916,RC,90847,HCPCS,Outpatient,,,227.45,136.47,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,170.59,75,,,percent of total billed charges,75% of total billed charges,170.59,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,181.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,174,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,102.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.47,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,159.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,109.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,204.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,102.35,268.22,
"Family psychotherapy, not including patient, 50 min",4507031,CDM,916,RC,90846,HCPCS,Outpatient,,,190.75,114.45,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.06,75,,,percent of total billed charges,75% of total billed charges,143.06,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,145.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,85.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,133.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,91.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,171.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,85.84,268.22,
"Psychotherapy, 60 min",4507032,CDM,914,RC,90837,HCPCS,Outpatient,,,175.05,105.03,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.29,75,,,percent of total billed charges,75% of total billed charges,131.29,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,140.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,133.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,78.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,84.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,157.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,78.77,268.22,
"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",4507033,CDM,914,RC,90791,HCPCS,Outpatient,,,191.7,115.02,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.78,75,,,percent of total billed charges,75% of total billed charges,143.78,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,153.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,146.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,86.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,134.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,115.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,134.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,92.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,172.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,86.27,268.22,
TEAM CONF W/O PAT-NPSYCH,4507035,CDM,940,RC,99368,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
TEAM CONF W/PAT-NPSYCH,4507036,CDM,940,RC,99366,HCPCS,Outpatient,,,111.6,66.96,,20.09,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,20.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.12,70,,,percent of total billed charges,70% of total billed charges,83.7,75,,,percent of total billed charges,75% of total billed charges,55.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,89.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,78.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,111.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,100.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.09,174,
MH HLTH/BEH FLY W/O PT ADD 15M,4507042,CDM,916,RC,96171,HCPCS,Outpatient,,,52,31.2,,9.36,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,9.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,26,50,,,percent of total billed charges,pays at 50% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,39,75,,,percent of total billed charges,75% of total billed charges,26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,41.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.36,52,
"Psychotherapy, 45 min",4507045,CDM,914,RC,90834,HCPCS,Outpatient,,,150,90,,268.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.44,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,112.5,75,,,percent of total billed charges,75% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,238.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,268.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.1,103,,,Fee Schedule,103% of CMS OPPS Rate,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,268.22,100,,,Fee Schedule,100% of CMS OPPS Rate,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of CMS OPPS Rate,67.5,268.22,
MH HLTH/BEH INTERV ADD 15M,4507047,CDM,914,RC,96159,HCPCS,Outpatient,,,57.63,34.58,,10.37,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,10.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.82,50,,,percent of total billed charges,pays at 50% of total billed charges,43.22,75,,,percent of total billed charges,75% of total billed charges,43.22,75,,,percent of total billed charges,75% of total billed charges,28.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57.63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,57.63,
MH HLTH/BEH GROUP ADD 15M,4507048,CDM,915,RC,96165,HCPCS,Outpatient,,,57.63,34.58,,10.37,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,10.37,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.82,50,,,percent of total billed charges,pays at 50% of total billed charges,43.22,75,,,percent of total billed charges,75% of total billed charges,43.22,75,,,percent of total billed charges,75% of total billed charges,28.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,46.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,57.63,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,51.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.37,57.63,
MH HLTH/BEH FLY W/PT ADD 15M,4507049,CDM,916,RC,96168,HCPCS,Outpatient,,,62.83,37.7,,11.31,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,11.31,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.42,50,,,percent of total billed charges,pays at 50% of total billed charges,47.12,75,,,percent of total billed charges,75% of total billed charges,47.12,75,,,percent of total billed charges,75% of total billed charges,31.42,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.83,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.31,62.83,
Use of external hot or cold packs,4539614,CDM,421,RC,97010,HCPCS,Outpatient,,,51.03,30.62,,21.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,35.72,70,,,percent of total billed charges,70% of total billed charges,38.27,75,,,percent of total billed charges,75% of total billed charges,10.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,39.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,22.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,230,,,Fee Schedule,230% of CMS OPPS Rate,24.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,191,
RE-EVALUATION-PT FOCUSED,4539651,CDM,424,RC,97002,HCPCS,Outpatient,,,85.95,51.57,,15.47,18,,,percent of total billed charges,pays at 18% of total charges,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.47,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42.98,50,,,percent of total billed charges,pays at 50% of total billed charges,60.17,70,,,percent of total billed charges,70% of total billed charges,64.46,75,,,percent of total billed charges,75% of total billed charges,42.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.95,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,77.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.47,191,
Manipulation of 1 or more regions of the body,4539702,CDM,421,RC,97140,HCPCS,Outpatient,,,64.8,38.88,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.36,70,,,percent of total billed charges,70% of total billed charges,48.6,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,51.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,49.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.17,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,29.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,45.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,31.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,58.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,10.15,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4539704,CDM,421,RC,97110,HCPCS,Outpatient,,,68.4,41.04,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.88,70,,,percent of total billed charges,70% of total billed charges,51.3,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,52.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,30.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,47.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,32.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,61.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
ELECTRICAL STIMULATION PT,4539714,CDM,420,RC,G0283,HCPCS,Outpatient,,,41.58,24.95,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.11,70,,,percent of total billed charges,70% of total billed charges,31.19,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,33.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,31.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,18.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,29.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,19.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,37.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.52,191,
EVALUATION EXPANDED NP,4539716,CDM,424,RC,97001,HCPCS,Outpatient,,,158.36,95.02,,28.5,18,,,percent of total billed charges,pays at 18% of total charges,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,79.18,50,,,percent of total billed charges,pays at 50% of total billed charges,110.85,70,,,percent of total billed charges,70% of total billed charges,118.77,75,,,percent of total billed charges,75% of total billed charges,79.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,126.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,110.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,110.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,142.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.82,191,
Use of external hot or cold packs,4539729,CDM,421,RC,97010,HCPCS,Outpatient,,,62.37,37.42,,21.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,10.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,191,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",4539734,CDM,421,RC,97016,HCPCS,Outpatient,,,51.03,30.62,,39.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.72,70,,,percent of total billed charges,70% of total billed charges,38.27,75,,,percent of total billed charges,75% of total billed charges,20.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.31,350,,,Fee Schedule,350% of CMS OPPS Rate,11.45,102,,,Fee Schedule,102% of CMS OPPS Rate,39.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,25.83,230,,,Fee Schedule,230% of CMS OPPS Rate,24.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8,191,
WHIRLPOOL - PT,4539758,CDM,421,RC,97022,HCPCS,Outpatient,,,63.45,38.07,,56.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,28.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,191,
"New patient office of other outpatient visit, typically 60 min",4550002,CDM,510,RC,99205,HCPCS,Outpatient,,,306.04,183.62,,55.09,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,55.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.53,75,,,percent of total billed charges,75% of total billed charges,153.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.09,306.04,
"New patient office of other outpatient visit, typically 45 min",4550003,CDM,510,RC,99204,HCPCS,Outpatient,,,389,233.4,,70.02,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,70.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.75,75,,,percent of total billed charges,75% of total billed charges,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,389,
"New patient office or other outpatient visit, typically 10 minutes",4550004,CDM,510,RC,99202,HCPCS,Outpatient,,,152,91.2,,27.36,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.36,152,
"New patient office or other outpatient visit, typically 30 min",4550006,CDM,510,RC,99203,HCPCS,Outpatient,,,228,136.8,,41.04,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,41.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171,75,,,percent of total billed charges,75% of total billed charges,114,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,136.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,159.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,228,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,205.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,228,
EA ADD'L PUNCH BIOPSY,4550007,CDM,510,RC,11101,HCPCS,Outpatient,,,122.77,73.66,,22.1,18,,,percent of total billed charges,pays at 18% of total charges,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.08,75,,,percent of total billed charges,75% of total billed charges,61.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,85.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,122.77,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.24,122.77,
"Established patient office or other outpatient, visit typically 40 minutes",4550020,CDM,510,RC,99215,HCPCS,Outpatient,,,333,199.8,,59.94,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,59.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.75,75,,,percent of total billed charges,75% of total billed charges,166.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,266.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,254.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,199.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,233.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,333,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,299.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,333,
"Established patient office or other outpatient visit, typically 25 minutes",4550022,CDM,510,RC,99214,HCPCS,Outpatient,,,236,141.6,,42.48,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,42.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177,75,,,percent of total billed charges,75% of total billed charges,118,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,188.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,141.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,180.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,165.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,165.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,236,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,212.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.48,236,
"Established patient office or other outpatient visit, typically 15 minutes",4550024,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
Outpatient visit of established patient requiring a physician,4550026,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
Outpatient visit of established patient not requiring a physician,4550027,CDM,510,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
DEBRIDEMENT SUB Q EA ADD. 20 SQ CM,4550029,CDM,510,RC,11045,HCPCS,Outpatient,,,893,535.8,,160.74,18,,,percent of total billed charges,pays at 18% of total charges,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,160.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.75,75,,,percent of total billed charges,75% of total billed charges,446.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,714.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,535.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,683.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,153.86,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,625.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,535.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,339.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,625.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,893,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,803.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,139.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.93,893,
DEBRIDEMENT TO BONE 1ST 20SQ CM OR LESS,4550030,CDM,510,RC,11044,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3715,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1411.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3715,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,4825.85,
DBRDMNT TO MSCLE 1ST 20SQ CM OR LESS,4550031,CDM,510,RC,11043,HCPCS,Outpatient,,,1605,963,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1605,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.75,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,1227.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,722.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1123.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,963,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,609.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1123.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,770.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1444.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1605,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,1869.61,
DEBRIDE MUSC/ FAS EA ADD'L 20 SQ CM,4550033,CDM,510,RC,11046,HCPCS,Outpatient,,,629,377.4,,113.22,18,,,percent of total billed charges,pays at 18% of total charges,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.75,75,,,percent of total billed charges,75% of total billed charges,314.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,503.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,377.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,481.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,440.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,377.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,239.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,440.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,629,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,566.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.56,629,
DBRDMNT TO SUBQ TISSUE 1ST 20 SQ CM,4550034,CDM,510,RC,11042,HCPCS,Outpatient,,,893,535.8,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,893,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,714.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,683.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,401.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,625.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,535.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,625.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,428.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,803.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,893,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,1200.6,
DEBRIDE BONE EA ADD'L 20 SQ CM,4550039,CDM,510,RC,11047,HCPCS,Outpatient,,,965.24,579.14,,173.74,18,,,percent of total billed charges,pays at 18% of total charges,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,173.74,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,723.93,75,,,percent of total billed charges,75% of total billed charges,482.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,772.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,579.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,738.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,166.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,675.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,579.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,366.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,675.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,965.24,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,868.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,151.25,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.25,965.24,
"CAST SUPPLIES, SHORT LEG SPLINT FIBERGL",4550046,CDM,510,RC,Q4046,HCPCS,Outpatient,,,79,47.4,,,,,,Other,Not Separately reimbursable,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,71.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,71.1,
WOUND VAC <=50 SQCM,4550071,CDM,510,RC,97605,HCPCS,Outpatient,,,473,283.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,179.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.12,581.14,
WOUND VAC > 50 SQ CM,4550072,CDM,510,RC,97606,HCPCS,Outpatient,,,865,519,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.75,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,692,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,661.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,389.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,519,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,328.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,605.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,415.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,778.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,135.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,135.55,1200.61,
TCPO2/ABI-MULTI LEVEL,4550112,CDM,921,RC,93923,HCPCS,Outpatient,,,169.26,101.56,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.48,70,,,percent of total billed charges,70% of total billed charges,126.95,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,129.48,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,76.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,118.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,81.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,152.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,468.02,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,4550113,CDM,921,RC,93922,HCPCS,Outpatient,,,295,177,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.5,70,,,percent of total billed charges,70% of total billed charges,221.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,236,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,225.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,132.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,206.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,141.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,265.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,46.23,373.66,
Removal of ear wax from one or both ears,4550117,CDM,510,RC,69210,HCPCS,Outpatient,,,132.88,79.73,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.66,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,106.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,101.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,59.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,50.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,63.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,119.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,20.82,184.98,
"Incision and drainage of hematoma, seroma or fluid collection",4550118,CDM,510,RC,10140,HCPCS,Outpatient,,,2702.5,1621.5,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2702.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2026.88,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2162,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2067.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1216.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1891.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1621.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1026.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1891.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1297.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2432.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2702.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1026.95,4825.85,
REMOVAL FOREIGN BODY,4550122,CDM,510,RC,10120,HCPCS,Outpatient,,,596,357.6,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,596,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,455.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,268.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,226.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,286.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,536.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,226.48,1200.6,
APPLY TOTAL CONTACT CAST LEG,4550123,CDM,510,RC,29445,HCPCS,Outpatient,,,805,483,,772.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.75,75,,,percent of total billed charges,75% of total billed charges,392.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,644,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.35,350,,,Fee Schedule,350% of CMS OPPS Rate,222.45,103,,,Fee Schedule,103% of CMS OPPS Rate,615.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,362.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,563.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,483,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,305.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,563.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,501.63,100,,,Fee Schedule,100% of CMS OPPS Rate,386.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,724.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,126.14,772.08,
UNNA BOOT STRAPPING,4550124,CDM,510,RC,29580,HCPCS,Outpatient,,,402,241.2,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.5,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,307.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,180.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,152.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,192.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,361.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,62.99,469.08,
APPLY BILATERAL UNNA BOOT,4550126,CDM,510,RC,29580,HCPCS,Outpatient,,,402,241.2,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.5,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,307.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,180.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,152.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,192.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,361.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,62.99,469.08,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",4550128,CDM,510,RC,97597,HCPCS,Outpatient,,,473,283.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,81.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,179.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,74.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.12,581.14,
DEBRIDEMENT OPEN WD EA ADD >20 SQ CM,4550129,CDM,510,RC,97598,HCPCS,Outpatient,,,216,129.6,,,,,,Other,Not Separately reimbursable,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,194.4,
Chemical destruction of pre-cancerous lesions of the skin,4550131,CDM,510,RC,17250,HCPCS,Outpatient,,,179,107.4,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.25,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,143.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,136.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,30.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,80.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,125.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,107.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,125.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,85.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,161.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,28.05,581.14,
WND PREP 100SQCM TRK/ARM/,4550132,CDM,510,RC,15002,HCPCS,Outpatient,,,5250,3150,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3937.5,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,4016.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,904.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3675,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3150,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1995,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3675,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2520,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,4725,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,822.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,822.68,5554.18,
APPLY SHORT LEG SPLINT,4550135,CDM,510,RC,29515,HCPCS,Outpatient,,,255.2,153.12,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.4,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,195.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,114.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,122.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,229.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.99,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,39.99,469.08,
DERMAGRAFT PER 1 SQ CM,4550136,CDM,636,RC,Q4106,HCPCS,Outpatient,,,89.4,53.64,,,,,,Other,Not Separately reimbursable,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.7,50,,,percent of total billed charges,pays at 50% of total billed charges,62.58,70,,,percent of total billed charges,70% of total billed charges,67.05,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,71.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,62.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.01,80.46,
EA ADD'L PUNCH BIOPSY,4550139,CDM,510,RC,11105,HCPCS,Outpatient,,,122.77,73.66,,,,,,Other,Not Separately reimbursable,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.08,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,98.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,85.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,85.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.24,110.49,
"INCISIONAL BIOPSY, SINGLE",4550140,CDM,510,RC,11106,HCPCS,Outpatient,,,716.8,430.08,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,573.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,548.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,272.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,344.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,645.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,112.32,1869.61,
WOUND PREP UP TO 100 SQ CM OF FEET,4550150,CDM,510,RC,15004,HCPCS,Outpatient,,,1605,963,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.75,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1284,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,1227.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,276.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,722.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1123.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,963,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,609.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1123.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,770.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1444.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,251.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,251.5,1869.61,
SINGLE PUNCH BIOPSY,4550300,CDM,510,RC,11104,HCPCS,Outpatient,,,280,168,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,280,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,106.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,280,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,1200.6,
Incision and drainage of abscess; simple or single and complex or multiple,4550310,CDM,510,RC,10060,HCPCS,Outpatient,,,473,283.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,473,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,179.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,581.14,
I&D ABCESS COMPL OR MULTI,4550320,CDM,510,RC,10061,HCPCS,Outpatient,,,525,315,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,525,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,401.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,252,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.5,1200.6,
I&D CMPLX POSTOP WND INFCTN,4550324,CDM,510,RC,10180,HCPCS,Outpatient,,,3189.65,1913.79,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3189.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2392.24,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2551.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2395.39,103,,,Fee Schedule,103% of CMS OPPS Rate,2440.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.34,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2232.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1913.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1212.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2232.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1531.03,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2870.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3189.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1212.07,8313.44,
Separation and removal of the entire nail plate or a portion of nail plate,4550330,CDM,510,RC,11730,HCPCS,Outpatient,,,158.61,95.17,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,158.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,158.61,103,,,Fee Schedule,103% of CMS OPPS Rate,121.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,71.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,111.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,76.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.61,100,,,Fee Schedule,100% of CMS OPPS Rate,142.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.85,581.14,
AVULSION OF NAIL PLATE EA,4550331,CDM,510,RC,11732,HCPCS,Outpatient,,,124.8,74.88,,,,,,Other,Not Separately reimbursable,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,99.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,87.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.56,112.32,
DEBRIDEMENT OF NAIL 1 TO 5,4550340,CDM,510,RC,11720,HCPCS,Outpatient,,,126.45,75.87,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.84,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,101.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,96.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,56.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.87,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,48.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,60.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,113.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,184.98,
Removal of 6 or more nails,4550342,CDM,510,RC,11721,HCPCS,Outpatient,,,126.24,75.74,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.68,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,96.57,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,56.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,88.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,47.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,88.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,60.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,113.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,19.78,184.98,
HBO PER 30 MIN,4550404,CDM,413,RC,G0277,HCPCS,Outpatient,,,347,208.2,,402.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,113.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,232.78,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,242.9,70,,,percent of total billed charges,70% of total billed charges,260.25,75,,,percent of total billed charges,75% of total billed charges,204.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,277.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.95,350,,,Fee Schedule,350% of CMS OPPS Rate,115.97,103,,,Fee Schedule,103% of CMS OPPS Rate,265.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,59.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,156.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,242.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,208.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,589,100,,,Case rate,Pays based on per visit ,242.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,261.51,100,,,Fee Schedule,100% of CMS OPPS Rate,166.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,312.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,113.7,100,,,Fee Schedule,100% of CMS OPPS Rate,54.37,589,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,4550405,CDM,510,RC,11401,HCPCS,Outpatient,,,782.95,469.77,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,782.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.21,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,626.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,598.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,352.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,548.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,469.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,297.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,548.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,375.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,704.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,297.52,1200.6,
EXCISIONAL BIOPSY OVER 4.0CM,4550406,CDM,510,RC,11406,HCPCS,Outpatient,,,1952.88,1171.73,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1952.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1464.66,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1562.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1493.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,878.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1367.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1171.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,742.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1367.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,937.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1757.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,742.09,4825.85,
INCISION & DRAINAGE LEG ABSCESS/HEMATOMA,4550603,CDM,510,RC,27603,HCPCS,Outpatient,,,5230.25,3138.15,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5230.25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3922.69,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4184.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2395.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4001.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2353.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3661.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3138.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1987.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3661.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2510.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,4707.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,5230.25,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1987.5,8313.44,
APLIGRAF PER 1 SQ CM,4550612,CDM,636,RC,Q4101,HCPCS,Outpatient,,,75.99,45.59,,,,,,Other,Not Separately reimbursable,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38,50,,,percent of total billed charges,pays at 50% of total billed charges,53.19,70,,,percent of total billed charges,70% of total billed charges,56.99,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,60.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,28.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,53.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.91,68.39,
APPLICATION OF MULTI LAYER COMPRESSION,4550632,CDM,510,RC,29581,HCPCS,Outpatient,,,302,181.2,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.5,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,241.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,231.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,135.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,211.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,114.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,211.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,144.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,271.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,47.32,469.08,
APPLICATION OF MULTI LAYER COMPRESS BILA,4550633,CDM,510,RC,29581,HCPCS,Outpatient,,,185.39,111.23,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.04,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,141.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.94,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,70.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,129.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,88.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,166.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,29.05,469.08,
APPLY SKIN SUB 1ST 25SQ CM TRK ARM LEG,4550650,CDM,510,RC,15271,HCPCS,Outpatient,,,2448.74,1469.24,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.56,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1958.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,1873.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,421.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1101.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1714.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1469.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,930.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1714.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2203.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,383.72,5554.18,
APPLY SKIN SUB 1ST 25SQ CM FAC HND FEET,4550651,CDM,510,RC,15275,HCPCS,Outpatient,,,2448.74,1469.24,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.56,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1958.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,1873.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,421.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1101.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1714.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1469.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,930.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1714.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2203.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,383.72,5554.18,
APPLY SKIN SUB ADDL 25SQ CM TRK ARM LEG,4550652,CDM,510,RC,15272,HCPCS,Outpatient,,,198,118.8,,,,,,Other,Not Separately reimbursable,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,158.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,138.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,138.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.03,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.03,178.2,
APPLY SKIN SUB 1ST 100SQ CM TRK ARM LEG,4550654,CDM,510,RC,15273,HCPCS,Outpatient,,,4036.86,2422.12,,10468.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2957.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2957.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3027.65,75,,,percent of total billed charges,75% of total billed charges,5323.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3229.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10350.68,350,,,Fee Schedule,350% of CMS OPPS Rate,3016.48,103,,,Fee Schedule,103% of CMS OPPS Rate,3088.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,695.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1816.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2825.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2422.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1534.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2825.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6801.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1937.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3633.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,632.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.33,100,,,Fee Schedule,100% of CMS OPPS Rate,632.58,10468.96,
APPLY SKIN SUB 1ST 100SQ CM FAC HND FEET,4550655,CDM,510,RC,15277,HCPCS,Outpatient,,,2448.74,1469.24,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.56,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1958.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.35,103,,,Fee Schedule,103% of CMS OPPS Rate,1873.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,421.92,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1101.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1714.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1469.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,930.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1714.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2203.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,383.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,383.72,5554.18,
PURAPLY ANTIMCRBL PER SQ CM,4550676,CDM,636,RC,Q4196,HCPCS,Outpatient,,,222,133.2,,,,,,Other,Not Separately reimbursable,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,50,,,percent of total billed charges,pays at 50% of total billed charges,155.4,70,,,percent of total billed charges,70% of total billed charges,166.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,177.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,155.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,133.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,155.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.79,199.8,
CAST BOOT,4551100,CDM,272,RC,,,Outpatient,,,117,70.2,,,,,,Other,Not Separately reimbursable,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.5,50,,,percent of total billed charges,pays at 50% of total billed charges,81.9,70,,,percent of total billed charges,70% of total billed charges,87.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.33,105.3,
CASTING SYSTEM SNGL,4551102,CDM,272,RC,,,Outpatient,,,180,108,,,,,,Other,Not Separately reimbursable,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,50,,,percent of total billed charges,pays at 50% of total billed charges,126,70,,,percent of total billed charges,70% of total billed charges,135,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,68.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,126,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,162,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.21,162,
DRESSING ABSORBENT ADHSV BORDER,4551103,CDM,272,RC,,,Outpatient,,,5.5,3.3,,,,,,Other,Not Separately reimbursable,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,50,,,percent of total billed charges,pays at 50% of total billed charges,3.85,70,,,percent of total billed charges,70% of total billed charges,4.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,4.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,4.95,
BLOOD GLUCOSE CHECK,4551106,CDM,300,RC,82962,HCPCS,Outpatient,,,11.25,6.75,,11.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges,8.44,75,,,percent of total billed charges,75% of total billed charges,5.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.48,350,,,Fee Schedule,350% of CMS OPPS Rate,3.34,102,,,Fee Schedule,102% of CMS OPPS Rate,8.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of UHC Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,7.54,230,,,Fee Schedule,230% of CMS OPPS Rate,5.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,11.61,
PRESSURE RELIEF HEEL PROTECTOR W WEDGE,4551107,CDM,272,RC,,,Outpatient,,,150,90,,,,,,Other,Not Separately reimbursable,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,135,
BURN TX SMALL LESS THAN 5 PRCNT BS AREA,4551108,CDM,510,RC,16020,HCPCS,Outpatient,,,473,283.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,473,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,378.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,361.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,212.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,283.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,179.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,331.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,227.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,425.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,473,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,581.14,
BURN TX MED 5 TO 10 PRCNT BS AREA,4551109,CDM,510,RC,16025,HCPCS,Outpatient,,,197,118.2,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,197,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,157.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,150.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,88.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,137.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,137.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,94.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,177.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,74.86,581.14,
BURN TX LRG GRTR THAN 10 PRCNT BS AREA,4551110,CDM,510,RC,16030,HCPCS,Outpatient,,,259.68,155.81,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,259.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,259.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.76,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,207.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,259.68,103,,,Fee Schedule,103% of CMS OPPS Rate,198.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,116.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,181.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,155.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,98.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,181.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,124.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,259.68,100,,,Fee Schedule,100% of CMS OPPS Rate,233.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,259.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,98.68,1200.6,
THERASKIN PER SQ CM,4551111,CDM,636,RC,Q4121,HCPCS,Outpatient,,,323.74,194.24,,,,,,Other,Not Separately reimbursable,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.87,50,,,percent of total billed charges,pays at 50% of total billed charges,226.62,70,,,percent of total billed charges,70% of total billed charges,242.81,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,258.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,226.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,291.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.73,291.37,
EPIFIX PER SQ CM,4554131,CDM,636,RC,Q4186,HCPCS,Outpatient,,,317.55,190.53,,,,,,Other,Not Separately reimbursable,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.78,50,,,percent of total billed charges,pays at 50% of total billed charges,222.29,70,,,percent of total billed charges,70% of total billed charges,238.16,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,254.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.29,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,285.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.76,285.8,
WOUND CARE AMERICAINE SPRAY,4559000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE MUPIROCIN OINT 2%,4559001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE BENZOCAINE SPRAY,4559002,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE LIDOCAINE TOPICAL 4%,4559003,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE LIDOCAINE JELLY 2%,4559004,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE SALINE BULLETS 0.9% 5ML,4559005,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE SALINE BULLETS 0.9% 15ML,4559006,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE SALINE POUR BOTTLE 250ML,4559007,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE SILVER NITRATE APPLICATOR,4559008,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE SILVER SULFADIAZINE CREAM,4559009,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE TRIAMCINOLONE 1% CREAM,4559010,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE ZEASBORB AF POWDER,4559011,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE LIDOCAINE 1% WITH EPI,4559012,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE LIDOCAINE 2 % WITH EPI,4559013,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE LIDOCAINE 1%,4559014,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE LIDOCAINE 2%,4559015,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE SANTYL OINTMENT,4559016,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE GENTAMICIN OINTMENT,4559017,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE IODOSORB CADEXOMER IODINE,4559018,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE AFRIN NASAL 0.05% SPRAY,4559019,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE REGENECARE SPRAY,4559020,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE METRONIDAZOLE 0.75% CREAM,4559021,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE POVIDONE PVP SWABSTICK,4559023,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE GELOCAST BANDAGE 4X10,4559024,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE POVIDONE-IODINE SOLN,4559025,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
REPAIR INTRMDT WOUND <=2.5 CM,4559026,CDM,510,RC,12041,HCPCS,Outpatient,,,1059,635.4,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1059,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,794.25,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,847.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,810.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,476.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,741.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,635.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,402.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,741.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,508.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,953.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1059,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,1200.61,
WOUND CARE LIDOCAINE OIN 5% 1.25 OZ,4559027,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
WOUND CARE HIBICLENS LIQ 4 OZ,4559028,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BRACE MEASUREMENT,4560001,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
GROUP THERAPEUTIC PROCEDU,4560002,CDM,420,RC,97150,HCPCS,Outpatient,,,54,32.4,,60.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,30.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,350,,,Fee Schedule,350% of CMS OPPS Rate,17.38,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.19,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,191,
GROUP THERAPEUTIC PROCEDU,4560003,CDM,430,RC,97150,HCPCS,Outpatient,,,54,32.4,,60.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,37.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.8,70,,,percent of total billed charges,70% of total billed charges,40.5,75,,,percent of total billed charges,75% of total billed charges,30.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,43.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.64,350,,,Fee Schedule,350% of CMS OPPS Rate,17.38,102,,,Fee Schedule,102% of CMS OPPS Rate,41.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,24.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,37.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,39.19,230,,,Fee Schedule,230% of CMS OPPS Rate,25.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,48.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,17.04,100,,,Fee Schedule,100% of CMS OPPS Rate,8.46,191,
GEN II UNLOAD SPIRIT-MED,4560022,CDM,270,RC,L1843,HCPCS,Outpatient,,,1541.5,924.9,,3662.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1034.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1034.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,770.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1079.05,70,,,percent of total billed charges,70% of total billed charges,1156.13,75,,,percent of total billed charges,75% of total billed charges,1862.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1233.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3620.65,350,,,Fee Schedule,350% of CMS OPPS Rate,1055.16,102,,,Fee Schedule,102% of CMS OPPS Rate,1179.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,265.6,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,693.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1079.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,924.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1034.47,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,585.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1079.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1034.47,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1541.5,230,,,Fee Schedule,230% of CMS OPPS Rate,739.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1034.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1387.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,241.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1034.47,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,241.55,3662.02,
SWEDEO ANKLE BRACE,4560055,CDM,270,RC,L1906,HCPCS,Outpatient,,,136.5,81.9,,456.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.25,50,,,percent of total billed charges,pays at 50% of total billed charges,95.55,70,,,percent of total billed charges,70% of total billed charges,102.38,75,,,percent of total billed charges,75% of total billed charges,232.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,109.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,451.36,350,,,Fee Schedule,350% of CMS OPPS Rate,131.54,102,,,Fee Schedule,102% of CMS OPPS Rate,104.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,61.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,51.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,136.5,230,,,Fee Schedule,230% of CMS OPPS Rate,65.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,100% of CMS OPPS Rate,122.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,128.96,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,21.39,456.52,
AIRCAST SPORT-STIRRUP L&R,4560056,CDM,270,RC,L4350,HCPCS,Outpatient,,,87,52.2,,348.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.5,50,,,percent of total billed charges,pays at 50% of total billed charges,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,177.44,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,345.03,350,,,Fee Schedule,350% of CMS OPPS Rate,100.55,102,,,Fee Schedule,102% of CMS OPPS Rate,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,33.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,87,230,,,Fee Schedule,230% of CMS OPPS Rate,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,100% of CMS OPPS Rate,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,98.58,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,13.63,348.97,
PATELLA STRAP,4560076,CDM,270,RC,L2999,HCPCS,Outpatient,,,48.5,29.1,,,,,,Other,Not Separately reimbursable,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.25,50,,,percent of total billed charges,pays at 50% of total billed charges,33.95,70,,,percent of total billed charges,70% of total billed charges,36.38,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,43.65,
WHFO PREFAB WRIST COCK UP,4560099,CDM,274,RC,L3908,HCPCS,Outpatient,,,107,64.2,,222.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,53.5,50,,,percent of total billed charges,pays at 50% of total billed charges,74.9,70,,,percent of total billed charges,70% of total billed charges,80.25,75,,,percent of total billed charges,75% of total billed charges,113.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,220.05,350,,,Fee Schedule,350% of CMS OPPS Rate,64.13,102,,,Fee Schedule,102% of CMS OPPS Rate,107,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,48.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,40.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,74.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,107,230,,,Fee Schedule,230% of CMS OPPS Rate,51.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,100% of CMS OPPS Rate,107,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,62.87,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,16.77,222.56,
STRAPPING KNEE,4560114,CDM,420,RC,29530,HCPCS,Outpatient,,,98.26,58.96,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,68.78,70,,,percent of total billed charges,70% of total billed charges,73.7,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,98.26,103,,,Fee Schedule,103% of CMS OPPS Rate,75.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,47.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.26,100,,,Fee Schedule,100% of CMS OPPS Rate,88.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,15.4,373.66,
"COMPRESSIONETTE 5""",4560132,CDM,271,RC,,,Outpatient,,,2,1.2,,,,,,Other,Not Separately reimbursable,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1,50,,,percent of total billed charges,pays at 50% of total billed charges,1.4,70,,,percent of total billed charges,70% of total billed charges,1.5,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,1.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.31,1.8,
PHONOPHORESIS GEL,4560134,CDM,271,RC,,,Outpatient,,,27.5,16.5,,,,,,Other,Not Separately reimbursable,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,50,,,percent of total billed charges,pays at 50% of total billed charges,19.25,70,,,percent of total billed charges,70% of total billed charges,20.63,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,10.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,19.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.31,24.75,
IONTOPHORESIS ELECTRODES,4560135,CDM,272,RC,,,Outpatient,,,44,26.4,,,,,,Other,Not Separately reimbursable,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22,50,,,percent of total billed charges,pays at 50% of total billed charges,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,16.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.89,39.6,
DEROYAL M4 ACL,4560136,CDM,274,RC,L1845,HCPCS,Outpatient,,,1297,778.2,,3555.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1004.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,648.5,50,,,percent of total billed charges,pays at 50% of total billed charges,907.9,70,,,percent of total billed charges,70% of total billed charges,972.75,75,,,percent of total billed charges,75% of total billed charges,1807.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1037.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3515.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1024.47,102,,,Fee Schedule,102% of CMS OPPS Rate,1297,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,223.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,583.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,907.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,778.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,492.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,907.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1297,230,,,Fee Schedule,230% of CMS OPPS Rate,622.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1297,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,203.24,3555.51,
TENS LEAD 2.75,4560190,CDM,290,RC,A4595,HCPCS,Outpatient,,,58.85,35.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.2,70,,,percent of total billed charges,70% of total billed charges,44.14,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,47.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.36,52.97,
TENS LEAD 2,4560191,CDM,290,RC,A4595,HCPCS,Outpatient,,,58.85,35.31,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.2,70,,,percent of total billed charges,70% of total billed charges,44.14,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,47.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.31,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,22.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,41.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.36,52.97,
DONJOY DEFIANCE OA,4560203,CDM,270,RC,L1846,HCPCS,Outpatient,,,1670.5,1002.3,,4455.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,835.25,50,,,percent of total billed charges,pays at 50% of total billed charges,1169.35,70,,,percent of total billed charges,70% of total billed charges,1252.88,75,,,percent of total billed charges,75% of total billed charges,2265.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1336.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4405.21,350,,,Fee Schedule,350% of CMS OPPS Rate,1283.8,102,,,Fee Schedule,102% of CMS OPPS Rate,1277.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,287.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,751.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1169.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1002.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,634.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1169.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1670.5,230,,,Fee Schedule,230% of CMS OPPS Rate,801.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,261.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,261.77,4455.55,
DONJOY DEFIANCE,4560204,CDM,270,RC,L1846,HCPCS,Outpatient,,,2114.75,1268.85,,4455.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1057.38,50,,,percent of total billed charges,pays at 50% of total billed charges,1480.33,70,,,percent of total billed charges,70% of total billed charges,1586.06,75,,,percent of total billed charges,75% of total billed charges,2265.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1691.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4405.21,350,,,Fee Schedule,350% of CMS OPPS Rate,1283.8,102,,,Fee Schedule,102% of CMS OPPS Rate,1617.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,364.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,951.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1480.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1268.85,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,803.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1480.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,2114.75,230,,,Fee Schedule,230% of CMS OPPS Rate,1015.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1903.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,331.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,331.38,4455.55,
TOWNSEND REBEL 99 OTS,4560243,CDM,274,RC,L1845,HCPCS,Outpatient,,,1297,778.2,,3555.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1004.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,648.5,50,,,percent of total billed charges,pays at 50% of total billed charges,907.9,70,,,percent of total billed charges,70% of total billed charges,972.75,75,,,percent of total billed charges,75% of total billed charges,1807.88,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1037.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3515.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1024.47,102,,,Fee Schedule,102% of CMS OPPS Rate,1297,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,223.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,583.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,907.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,778.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,492.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,907.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1297,230,,,Fee Schedule,230% of CMS OPPS Rate,622.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1297,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,203.24,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1004.38,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,203.24,3555.51,
TOWNSEND PREMIER,4560282,CDM,274,RC,L1846,HCPCS,Outpatient,,,1368,820.8,,4455.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,684,50,,,percent of total billed charges,pays at 50% of total billed charges,957.6,70,,,percent of total billed charges,70% of total billed charges,1026,75,,,percent of total billed charges,75% of total billed charges,2265.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1094.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4405.21,350,,,Fee Schedule,350% of CMS OPPS Rate,1283.8,102,,,Fee Schedule,102% of CMS OPPS Rate,1368,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,235.71,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,615.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,957.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,820.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,519.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,957.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1368,230,,,Fee Schedule,230% of CMS OPPS Rate,656.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1368,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,214.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,214.37,4455.55,
TOWNS REBEL 99-PRO CUSTOM,4560283,CDM,274,RC,L1846,HCPCS,Outpatient,,,1519.5,911.7,,4455.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1258.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,759.75,50,,,percent of total billed charges,pays at 50% of total billed charges,1063.65,70,,,percent of total billed charges,70% of total billed charges,1139.63,75,,,percent of total billed charges,75% of total billed charges,2265.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1215.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4405.21,350,,,Fee Schedule,350% of CMS OPPS Rate,1283.8,102,,,Fee Schedule,102% of CMS OPPS Rate,1519.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,261.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,683.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1063.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,911.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,577.41,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1063.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% OF CMS OPPS RATE,1519.5,230,,,Fee Schedule,230% of CMS OPPS Rate,729.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1519.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,238.11,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,1258.63,100,,,Fee Schedule,pays at 100% CMS OPPS RATE,238.11,4455.55,
SWALLOW CURRENT STATUS,4562010,CDM,440,RC,G8996,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SWALLOW GOAL STATUS,4562020,CDM,440,RC,G8997,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SWALLOW D/C STATUS,4562030,CDM,440,RC,G8998,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOTOR SPEECH CURRENT STATUS,4562110,CDM,440,RC,G8999,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOTOR SPEECH GOAL STATUS,4562120,CDM,440,RC,G9186,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOTOR SPEECH D/C STATUS,4562130,CDM,440,RC,G9158,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG COMP CURRENT STATUS,4562210,CDM,440,RC,G9159,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG COMP GOAL STATUS,4562220,CDM,440,RC,G9160,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG COMP D/C STATUS,4562230,CDM,440,RC,G9161,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG EXPRESS CURRENT STATUS,4562310,CDM,440,RC,G9162,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG EXPRESS GOAL STATUS,4562320,CDM,440,RC,G9163,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
LANG EXPRESS D/C STATUS,4562330,CDM,440,RC,G9164,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ATTEN CURRENT STATUS,4562410,CDM,440,RC,G9165,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ATTEN GOAL STATUS,4562420,CDM,440,RC,G9166,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ATTEN D/C STATUS,4562430,CDM,440,RC,G9167,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MEMORY CURRENT STATUS,4562510,CDM,440,RC,G9168,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MEMORY GOAL STATUS,4562520,CDM,440,RC,G9169,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MEMORY D/C STATUS,4562530,CDM,440,RC,G9170,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
VOICE CURRENT STATUS,4562610,CDM,440,RC,G9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
VOICE GOAL STATUS,4562620,CDM,440,RC,G9172,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
VOICE D/C STATUS,4562630,CDM,440,RC,G9173,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SPEECH LANG CURRENT STATUS,4562710,CDM,440,RC,G9174,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SPEECH LANG GOAL STATUS,4562720,CDM,440,RC,G9175,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SPEECH LANG D/C STATUS,4562730,CDM,440,RC,G9176,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY CURRENT PT,4563010,CDM,420,RC,G8978,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY GOAL PT,4563020,CDM,420,RC,G8979,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY D/C PT,4563030,CDM,420,RC,G8980,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS CURRENT PT,4563110,CDM,420,RC,G8981,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS GOAL PT,4563120,CDM,420,RC,G8982,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS D/C PT,4563130,CDM,420,RC,G8983,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY CURRENT PT,4563210,CDM,420,RC,G8984,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY GOAL PT,4563220,CDM,420,RC,G8985,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY D/C PT,4563230,CDM,420,RC,G8986,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE CURRENT PT,4563310,CDM,420,RC,G8987,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE GOAL PT,4563320,CDM,420,RC,G8988,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE D/C PT,4563330,CDM,420,RC,G8989,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT CURRENT PT,4563410,CDM,420,RC,G8990,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT GOAL PT,4563420,CDM,420,RC,G8991,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT D/C PT,4563430,CDM,420,RC,G8992,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT CURRENT PT,4563510,CDM,420,RC,G8993,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT GOAL PT,4563520,CDM,420,RC,G8994,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT D/C PT,4563530,CDM,420,RC,G8995,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY CURRENT OT,4564010,CDM,430,RC,G8978,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY GOAL OT,4564020,CDM,430,RC,G8979,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
MOBILITY D/C OT,4564030,CDM,430,RC,G8980,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS CURRENT OT,4564110,CDM,430,RC,G8981,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS GOAL OT,4564120,CDM,430,RC,G8982,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
BODY POS D/C OT,4564130,CDM,430,RC,G8983,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY CURRENT OT,4564210,CDM,430,RC,G8984,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY GOAL OT,4564220,CDM,430,RC,G8985,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
CARRY D/C OT,4564230,CDM,430,RC,G8986,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE CURRENT OT,4564310,CDM,430,RC,G8987,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE GOAL OT,4564320,CDM,430,RC,G8988,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SELF CARE D/C OT,4564330,CDM,430,RC,G8989,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT CURRENT OT,4564410,CDM,430,RC,G8990,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT GOAL OT,4564420,CDM,430,RC,G8991,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
OTHER PT/OT D/C OT,4564430,CDM,430,RC,G8992,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT CURRENT OT,4564510,CDM,430,RC,G8993,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT GOAL OT,4564520,CDM,430,RC,G8994,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
SUB PT/OT D/C OT,4564530,CDM,430,RC,G8995,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,191,
ROM REPORT EA EXT/TRUNK,4569302,CDM,420,RC,95851,HCPCS,Outpatient,,,47.79,28.67,,26.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.45,70,,,percent of total billed charges,70% of total billed charges,35.84,75,,,percent of total billed charges,75% of total billed charges,13.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.57,350,,,Fee Schedule,350% of CMS OPPS Rate,7.74,102,,,Fee Schedule,102% of CMS OPPS Rate,36.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,33.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,17.46,230,,,Fee Schedule,230% of CMS OPPS Rate,22.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,43.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,191,
ROM REPORT EA EXT/TRUNK,4569402,CDM,430,RC,95851,HCPCS,Outpatient,,,47.79,28.67,,26.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,7.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.45,70,,,percent of total billed charges,70% of total billed charges,35.84,75,,,percent of total billed charges,75% of total billed charges,13.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.57,350,,,Fee Schedule,350% of CMS OPPS Rate,7.74,102,,,Fee Schedule,102% of CMS OPPS Rate,36.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,21.51,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,33.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,17.46,230,,,Fee Schedule,230% of CMS OPPS Rate,22.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,43.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.59,100,,,Fee Schedule,100% of CMS OPPS Rate,7.49,191,
ROM REPORT HAND,4569403,CDM,430,RC,95852,HCPCS,Outpatient,,,40.59,24.35,,18.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.56,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,28.41,70,,,percent of total billed charges,70% of total billed charges,30.44,75,,,percent of total billed charges,75% of total billed charges,9.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,32.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.55,350,,,Fee Schedule,350% of CMS OPPS Rate,5.41,102,,,Fee Schedule,102% of CMS OPPS Rate,31.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.99,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,18.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.19,230,,,Fee Schedule,230% of CMS OPPS Rate,19.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,36.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.36,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,100,,,Fee Schedule,100% of CMS OPPS Rate,5.3,191,
COMMUNITY WORK REINTERGRATION,4569542,CDM,420,RC,97537,HCPCS,Outpatient,,,142.65,85.59,,107.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,68.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,99.86,70,,,percent of total billed charges,70% of total billed charges,106.99,75,,,percent of total billed charges,75% of total billed charges,54.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,114.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.05,350,,,Fee Schedule,350% of CMS OPPS Rate,30.91,102,,,Fee Schedule,102% of CMS OPPS Rate,109.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,64.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,99.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,69.69,230,,,Fee Schedule,230% of CMS OPPS Rate,68.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,128.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.35,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,30.3,100,,,Fee Schedule,100% of CMS OPPS Rate,22.35,191,
COGNITIVE TRAINING INIT 15,4569550,CDM,434,RC,97129,HCPCS,Outpatient,,,60.35,36.21,,77.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.18,50,,,percent of total billed charges,pays at 50% of total billed charges,42.25,70,,,percent of total billed charges,70% of total billed charges,45.26,75,,,percent of total billed charges,75% of total billed charges,39.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.23,350,,,Fee Schedule,350% of CMS OPPS Rate,22.22,102,,,Fee Schedule,102% of CMS OPPS Rate,46.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,27.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,42.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.09,230,,,Fee Schedule,230% of CMS OPPS Rate,28.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,54.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,9.46,191,
COGNITIVE TRAIN ADD 15,4569555,CDM,434,RC,97130,HCPCS,Outpatient,,,55.35,33.21,,74.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.68,50,,,percent of total billed charges,pays at 50% of total billed charges,38.75,70,,,percent of total billed charges,70% of total billed charges,41.51,75,,,percent of total billed charges,75% of total billed charges,37.98,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,44.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.85,350,,,Fee Schedule,350% of CMS OPPS Rate,21.52,102,,,Fee Schedule,102% of CMS OPPS Rate,42.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,9.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,24.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,38.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,38.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,48.53,230,,,Fee Schedule,230% of CMS OPPS Rate,26.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,100,,,Fee Schedule,100% of CMS OPPS Rate,8.67,191,
Use of external hot or cold packs,4569614,CDM,421,RC,97010,HCPCS,Outpatient,,,62.37,37.42,,21.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,10.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,191,
ORTHOTIC FIT/TRAINING 15E,4569622,CDM,420,RC,97760,HCPCS,Outpatient,,,68.76,41.26,,160.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,48.13,70,,,percent of total billed charges,70% of total billed charges,51.57,75,,,percent of total billed charges,75% of total billed charges,81.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,55.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.31,350,,,Fee Schedule,350% of CMS OPPS Rate,46.13,102,,,Fee Schedule,102% of CMS OPPS Rate,52.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,30.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,48.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,48.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,104.03,230,,,Fee Schedule,230% of CMS OPPS Rate,33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,61.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,191,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",4569631,CDM,421,RC,97530,HCPCS,Outpatient,,,113,67.8,,123.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,62.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.12,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,80.25,230,,,Fee Schedule,230% of CMS OPPS Rate,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,191,
COMPLEX EVALUATION - PT,4569650,CDM,424,RC,97001,HCPCS,Outpatient,,,215.55,129.33,,38.8,18,,,percent of total billed charges,pays at 18% of total charges,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.78,50,,,percent of total billed charges,pays at 50% of total billed charges,150.89,70,,,percent of total billed charges,70% of total billed charges,161.66,75,,,percent of total billed charges,75% of total billed charges,107.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,172.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,129.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,164.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,150.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,150.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,215.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,194,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.78,215.55,
RE EVALUATION PT,4569651,CDM,424,RC,97164,HCPCS,Outpatient,,,90,54,,234.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,116.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63,70,,,percent of total billed charges,70% of total billed charges,67.5,75,,,percent of total billed charges,75% of total billed charges,119.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,231.49,350,,,Fee Schedule,350% of CMS OPPS Rate,67.46,102,,,Fee Schedule,102% of CMS OPPS Rate,68.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,40.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,152.12,230,,,Fee Schedule,230% of CMS OPPS Rate,43.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,40.5,234.14,
RE-EVALUATION-EXPANDED-PT,4569652,CDM,424,RC,97002,HCPCS,Outpatient,,,106.65,63.99,,19.2,18,,,percent of total billed charges,pays at 18% of total charges,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.33,50,,,percent of total billed charges,pays at 50% of total billed charges,74.66,70,,,percent of total billed charges,70% of total billed charges,79.99,75,,,percent of total billed charges,75% of total billed charges,53.33,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,85.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,63.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,74.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,95.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.71,191,
FUNCTIONAL TESTING 15MNEA,4569660,CDM,420,RC,97750,HCPCS,Outpatient,,,75.68,45.41,,113.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.98,70,,,percent of total billed charges,70% of total billed charges,56.76,75,,,percent of total billed charges,75% of total billed charges,57.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.86,350,,,Fee Schedule,350% of CMS OPPS Rate,32.6,102,,,Fee Schedule,102% of CMS OPPS Rate,57.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,34.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,52.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,52.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,73.51,230,,,Fee Schedule,230% of CMS OPPS Rate,36.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,68.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,11.86,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4569668,CDM,421,RC,97110,HCPCS,Outpatient,,,90.73,54.44,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,63.51,70,,,percent of total billed charges,70% of total billed charges,68.05,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,72.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,69.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,63.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,43.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,81.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
Manipulation of 1 or more regions of the body,4569702,CDM,421,RC,97140,HCPCS,Outpatient,,,83,49.8,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,191,
CONTRAST BATH-PT EA15MN,4569703,CDM,421,RC,97034,HCPCS,Outpatient,,,43.56,26.14,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.49,70,,,percent of total billed charges,70% of total billed charges,32.67,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,34.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,33.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,20.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,39.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.83,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4569704,CDM,421,RC,97110,HCPCS,Outpatient,,,89,53.4,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",4569705,CDM,420,RC,97597,HCPCS,Outpatient,,,169.7,101.82,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.79,70,,,percent of total billed charges,70% of total billed charges,127.28,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,129.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,81.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,152.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,581.14,
A technique used by physical therapists to restore normal body movement patterns,4569706,CDM,421,RC,97112,HCPCS,Outpatient,,,103,61.8,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,16.14,191,
COMPUTER DYN POSTUROGRAPH,4569710,CDM,421,RC,92548,HCPCS,Outpatient,,,232.65,139.59,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,162.86,70,,,percent of total billed charges,70% of total billed charges,174.49,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,177.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,104.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,162.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,111.67,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,209.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,36.46,373.66,
ISOKINETIC RETEST 15MN PT,4569711,CDM,421,RC,97750,HCPCS,Outpatient,,,120,72,,113.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84,70,,,percent of total billed charges,70% of total billed charges,90,75,,,percent of total billed charges,75% of total billed charges,57.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.86,350,,,Fee Schedule,350% of CMS OPPS Rate,32.6,102,,,Fee Schedule,102% of CMS OPPS Rate,91.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,73.51,230,,,Fee Schedule,230% of CMS OPPS Rate,57.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,108,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,18.8,191,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,4569713,CDM,421,RC,97033,HCPCS,Outpatient,,,77.36,46.42,,66.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.15,70,,,percent of total billed charges,70% of total billed charges,58.02,75,,,percent of total billed charges,75% of total billed charges,33.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.42,350,,,Fee Schedule,350% of CMS OPPS Rate,19.06,102,,,Fee Schedule,102% of CMS OPPS Rate,59.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,54.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,42.99,230,,,Fee Schedule,230% of CMS OPPS Rate,37.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,191,
ELECTRICAL STIMULATION PT,4569714,CDM,420,RC,G0283,HCPCS,Outpatient,,,44,26.4,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,191,
Repeated application to one or more parts of the body,4569715,CDM,420,RC,97032,HCPCS,Outpatient,,,48.4,29.04,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.88,70,,,percent of total billed charges,70% of total billed charges,36.3,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,37.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,33.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,23.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,43.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,191,
PT EVAL HIGH COMP 45MIN,4569716,CDM,424,RC,97163,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
EVALUATION DETAILED NP,4569717,CDM,424,RC,97001,HCPCS,Outpatient,,,194,116.4,,34.92,18,,,percent of total billed charges,pays at 18% of total charges,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97,50,,,percent of total billed charges,pays at 50% of total billed charges,135.8,70,,,percent of total billed charges,70% of total billed charges,145.5,75,,,percent of total billed charges,75% of total billed charges,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,194,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,174.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.4,194,
ISOKINETIC TEST 15MIN-PT,4569718,CDM,421,RC,97750,HCPCS,Outpatient,,,240,144,,113.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168,70,,,percent of total billed charges,70% of total billed charges,180,75,,,percent of total billed charges,75% of total billed charges,57.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.86,350,,,Fee Schedule,350% of CMS OPPS Rate,32.6,102,,,Fee Schedule,102% of CMS OPPS Rate,183.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,41.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,108,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,73.51,230,,,Fee Schedule,230% of CMS OPPS Rate,115.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,216,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,100,,,Fee Schedule,100% of CMS OPPS Rate,31.96,216,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4569719,CDM,421,RC,97110,HCPCS,Outpatient,,,81.65,48.99,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,57.16,70,,,percent of total billed charges,70% of total billed charges,61.24,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,65.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,62.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,57.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,57.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,39.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,73.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
A type of physical therapy,4569724,CDM,421,RC,97116,HCPCS,Outpatient,,,89,53.4,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.95,191,
Occupational therapy,4569725,CDM,421,RC,97535,HCPCS,Outpatient,,,99,59.4,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.51,191,
NON SELECT DEBRIDEMENT PT,4569726,CDM,420,RC,97602,HCPCS,Outpatient,,,139.52,83.71,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,139.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.66,70,,,percent of total billed charges,70% of total billed charges,104.64,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,111.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,139.52,103,,,Fee Schedule,103% of CMS OPPS Rate,106.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,24.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,62.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,97.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,66.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139.52,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,21.86,581.14,
Use of external hot or cold packs,4569729,CDM,421,RC,97010,HCPCS,Outpatient,,,62.37,37.42,,21.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,10.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,191,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",4569734,CDM,421,RC,97016,HCPCS,Outpatient,,,51.03,30.62,,39.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.72,70,,,percent of total billed charges,70% of total billed charges,38.27,75,,,percent of total billed charges,75% of total billed charges,20.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.31,350,,,Fee Schedule,350% of CMS OPPS Rate,11.45,102,,,Fee Schedule,102% of CMS OPPS Rate,39.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,25.83,230,,,Fee Schedule,230% of CMS OPPS Rate,24.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8,191,
Use of massage,4569736,CDM,421,RC,97124,HCPCS,Outpatient,,,61.05,36.63,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,42.74,70,,,percent of total billed charges,70% of total billed charges,45.79,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,48.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,46.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,27.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,42.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,36.63,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,42.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,29.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,54.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.57,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,9.57,191,
Light-based method to treat pain and inflammation,4569739,CDM,421,RC,97026,HCPCS,Outpatient,,,44,26.4,,22.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,11.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,350,,,Fee Schedule,350% of CMS OPPS Rate,6.4,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.42,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,191,
PT EVAL MOD COMP 30MIN,4569740,CDM,424,RC,97162,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
BIOFEEDBACK INITIAL 15,4569742,CDM,424,RC,90912,HCPCS,Outpatient,,,190,114,,147.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95,50,,,percent of total billed charges,pays at 50% of total billed charges,133,70,,,percent of total billed charges,70% of total billed charges,142.5,75,,,percent of total billed charges,75% of total billed charges,74.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,152,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,145.39,350,,,Fee Schedule,350% of CMS OPPS Rate,42.37,102,,,Fee Schedule,102% of CMS OPPS Rate,145.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,85.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,133,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,230,,,Fee Schedule,230% of CMS OPPS Rate,91.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,171,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,41.54,100,,,Fee Schedule,100% of CMS OPPS Rate,29.77,191,
BIOFEEDBACK EACH ADD 15,4569744,CDM,424,RC,90913,HCPCS,Outpatient,,,79,47.4,,84.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,23.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,39.5,50,,,percent of total billed charges,pays at 50% of total billed charges,55.3,70,,,percent of total billed charges,70% of total billed charges,59.25,75,,,percent of total billed charges,75% of total billed charges,42.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,63.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.41,350,,,Fee Schedule,350% of CMS OPPS Rate,24.31,102,,,Fee Schedule,102% of CMS OPPS Rate,60.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,35.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,55.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,54.81,230,,,Fee Schedule,230% of CMS OPPS Rate,37.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,71.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.38,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,23.83,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,191,
TENS APPLICATION - PT,4569749,CDM,420,RC,64550,HCPCS,Outpatient,,,94.55,56.73,,17.02,18,,,percent of total billed charges,pays at 18% of total charges,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.1,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,66.19,70,,,percent of total billed charges,70% of total billed charges,70.91,75,,,percent of total billed charges,75% of total billed charges,47.28,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,75.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,56.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.29,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,66.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,66.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,94.55,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,85.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.82,191,
Form of decompression therapy of the spine,4569755,CDM,421,RC,97012,HCPCS,Outpatient,,,45.77,27.46,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.04,70,,,percent of total billed charges,70% of total billed charges,34.33,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,35.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,32.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,21.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,41.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.17,191,
Form of decompression therapy of the spine,4569756,CDM,421,RC,97012,HCPCS,Outpatient,,,45.77,27.46,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.04,70,,,percent of total billed charges,70% of total billed charges,34.33,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,36.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,35.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,20.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,32.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,21.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,41.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.17,191,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",4569757,CDM,421,RC,97035,HCPCS,Outpatient,,,36.96,22.18,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.87,70,,,percent of total billed charges,70% of total billed charges,27.72,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,29.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,28.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,16.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,25.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,25.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,17.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,5.79,191,
WHIRLPOOL - PT,4569758,CDM,421,RC,97022,HCPCS,Outpatient,,,63.45,38.07,,56.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,28.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,191,
FLUIDOTHERAPY - PT,4569759,CDM,421,RC,97022,HCPCS,Outpatient,,,63.45,38.07,,56.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,28.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,191,
Use of massage,4569761,CDM,421,RC,97124,HCPCS,Outpatient,,,85.95,51.57,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,60.17,70,,,percent of total billed charges,70% of total billed charges,64.46,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,65.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,38.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,60.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,41.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.47,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.47,191,
DORSAL LEAF SPLINT,4569781,CDM,271,RC,,,Outpatient,,,172,103.2,,30.96,18,,,percent of total billed charges,pays at 18% of total charges,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86,50,,,percent of total billed charges,pays at 50% of total billed charges,120.4,70,,,percent of total billed charges,70% of total billed charges,129,75,,,percent of total billed charges,75% of total billed charges,86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,137.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,103.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,131.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,120.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,172,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,154.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.95,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.95,172,
EVALUATION COMPREHENS NP,4569790,CDM,424,RC,97001,HCPCS,Outpatient,,,194,116.4,,34.92,18,,,percent of total billed charges,pays at 18% of total charges,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,97,50,,,percent of total billed charges,pays at 50% of total billed charges,135.8,70,,,percent of total billed charges,70% of total billed charges,145.5,75,,,percent of total billed charges,75% of total billed charges,97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,155.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,148.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,33.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,135.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,194,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,174.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.4,194,
DRY NEEDLE 1-2 MUSCL,4569792,CDM,421,RC,20560,HCPCS,Outpatient,,,76,45.6,,80.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38,50,,,percent of total billed charges,pays at 50% of total billed charges,53.2,70,,,percent of total billed charges,70% of total billed charges,57,75,,,percent of total billed charges,75% of total billed charges,40.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,60.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.13,103,,,Fee Schedule,103% of CMS OPPS Rate,58.14,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,34.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,53.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,36.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,68.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,11.91,191,
DRY NEEDLE >2 MUSCL,4569793,CDM,421,RC,20561,HCPCS,Outpatient,,,96,57.6,,80.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48,50,,,percent of total billed charges,pays at 50% of total billed charges,67.2,70,,,percent of total billed charges,70% of total billed charges,72,75,,,percent of total billed charges,75% of total billed charges,40.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,76.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.13,103,,,Fee Schedule,103% of CMS OPPS Rate,73.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,43.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,57.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,67.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,46.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,86.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.04,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,191,
CANALITH REPOSITIONING,4569799,CDM,420,RC,95992,HCPCS,Outpatient,,,115,69,,124.86,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,80.5,70,,,percent of total billed charges,70% of total billed charges,86.25,75,,,percent of total billed charges,75% of total billed charges,63.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,123.45,350,,,Fee Schedule,350% of CMS OPPS Rate,35.98,102,,,Fee Schedule,102% of CMS OPPS Rate,87.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,51.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,81.12,230,,,Fee Schedule,230% of CMS OPPS Rate,55.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,103.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,100,,,Fee Schedule,100% of CMS OPPS Rate,18.02,191,
PT EVAL LOW COMP,4569800,CDM,424,RC,97161,HCPCS,Outpatient,,,249,149.4,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,74.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,172.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,174.3,70,,,percent of total billed charges,70% of total billed charges,186.75,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,199.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,190.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,112.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,149.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,174.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,119.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,224.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,74.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,74.48,339.42,
OT EVAL LOW COMP 30MIN,4569801,CDM,434,RC,97165,HCPCS,Outpatient,,,263,157.8,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,184.1,70,,,percent of total billed charges,70% of total billed charges,197.25,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,201.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,118.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,184.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,126.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,236.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
Manipulation of 1 or more regions of the body,4569802,CDM,430,RC,97140,HCPCS,Outpatient,,,83,49.8,,91.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,25.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,57.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.1,70,,,percent of total billed charges,70% of total billed charges,62.25,75,,,percent of total billed charges,75% of total billed charges,46.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,66.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.79,350,,,Fee Schedule,350% of CMS OPPS Rate,26.46,102,,,Fee Schedule,102% of CMS OPPS Rate,63.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,49.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,59.66,230,,,Fee Schedule,230% of CMS OPPS Rate,39.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,74.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,25.94,100,,,Fee Schedule,100% of CMS OPPS Rate,13.01,191,
CONTRAST BATH-OT EA 15MN,4569803,CDM,431,RC,97034,HCPCS,Outpatient,,,44,26.4,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,191,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4569804,CDM,431,RC,97110,HCPCS,Outpatient,,,89,53.4,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,62.3,70,,,percent of total billed charges,70% of total billed charges,66.75,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,71.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,68.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,40.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,53.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,62.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,42.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",4569805,CDM,431,RC,97597,HCPCS,Outpatient,,,169.7,101.82,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,118.79,70,,,percent of total billed charges,70% of total billed charges,127.28,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,129.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.82,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,118.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,81.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,152.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,581.14,
Occupational therapy,4569806,CDM,431,RC,97535,HCPCS,Outpatient,,,99,59.4,,109.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.3,70,,,percent of total billed charges,70% of total billed charges,74.25,75,,,percent of total billed charges,75% of total billed charges,55.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.75,350,,,Fee Schedule,350% of CMS OPPS Rate,31.69,102,,,Fee Schedule,102% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.46,230,,,Fee Schedule,230% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,100,,,Fee Schedule,100% of CMS OPPS Rate,15.51,191,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",4569810,CDM,431,RC,97530,HCPCS,Outpatient,,,113,67.8,,123.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,79.1,70,,,percent of total billed charges,70% of total billed charges,84.75,75,,,percent of total billed charges,75% of total billed charges,62.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,90.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.12,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,86.45,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,50.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,79.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,80.25,230,,,Fee Schedule,230% of CMS OPPS Rate,54.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,101.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,191,
A technique used by physical therapists to restore normal body movement patterns,4569811,CDM,431,RC,97112,HCPCS,Outpatient,,,103,61.8,,113.88,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,57.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.6,350,,,Fee Schedule,350% of CMS OPPS Rate,32.81,102,,,Fee Schedule,102% of CMS OPPS Rate,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,73.99,230,,,Fee Schedule,230% of CMS OPPS Rate,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,32.17,100,,,Fee Schedule,100% of CMS OPPS Rate,16.14,191,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,4569813,CDM,431,RC,97033,HCPCS,Outpatient,,,77.36,46.42,,66.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,42.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.15,70,,,percent of total billed charges,70% of total billed charges,58.02,75,,,percent of total billed charges,75% of total billed charges,33.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.42,350,,,Fee Schedule,350% of CMS OPPS Rate,19.06,102,,,Fee Schedule,102% of CMS OPPS Rate,59.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,54.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,42.99,230,,,Fee Schedule,230% of CMS OPPS Rate,37.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,18.69,100,,,Fee Schedule,100% of CMS OPPS Rate,12.12,191,
NON WND ELECT STIM,4569814,CDM,430,RC,G0283,HCPCS,Outpatient,,,44,26.4,,40.82,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,20.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.36,350,,,Fee Schedule,350% of CMS OPPS Rate,11.76,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,26.52,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,11.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6.89,191,
Repeated application to one or more parts of the body,4569815,CDM,430,RC,97032,HCPCS,Outpatient,,,48.4,29.04,,49.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.88,70,,,percent of total billed charges,70% of total billed charges,36.3,75,,,percent of total billed charges,75% of total billed charges,25.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,38.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.65,350,,,Fee Schedule,350% of CMS OPPS Rate,14.18,102,,,Fee Schedule,102% of CMS OPPS Rate,37.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,33.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,31.97,230,,,Fee Schedule,230% of CMS OPPS Rate,23.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,43.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.9,100,,,Fee Schedule,100% of CMS OPPS Rate,7.58,191,
OT EVAL HIGH COMP 60MIN,4569816,CDM,434,RC,97167,HCPCS,Outpatient,,,262,157.2,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.4,70,,,percent of total billed charges,70% of total billed charges,196.5,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,200.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,117.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,125.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,235.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
EVALUATION DETAILED,4569817,CDM,434,RC,97003,HCPCS,Outpatient,,,173.34,104,,31.2,18,,,percent of total billed charges,pays at 18% of total charges,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.67,50,,,percent of total billed charges,pays at 50% of total billed charges,121.34,70,,,percent of total billed charges,70% of total billed charges,130.01,75,,,percent of total billed charges,75% of total billed charges,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,121.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,173.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,156.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,191,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",4569823,CDM,431,RC,97530,HCPCS,Outpatient,,,77.36,46.42,,123.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,83.09,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,54.15,70,,,percent of total billed charges,70% of total billed charges,58.02,75,,,percent of total billed charges,75% of total billed charges,62.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,61.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.12,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,59.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.81,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,54.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,54.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,80.25,230,,,Fee Schedule,230% of CMS OPPS Rate,37.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,69.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,13.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,34.89,100,,,Fee Schedule,100% of CMS OPPS Rate,13.35,191,
RE EVALUATION  OT,4569824,CDM,434,RC,97168,HCPCS,Outpatient,,,105.42,63.25,,233.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.58,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,65.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.64,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.79,70,,,percent of total billed charges,70% of total billed charges,79.07,75,,,percent of total billed charges,75% of total billed charges,118.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.44,350,,,Fee Schedule,350% of CMS OPPS Rate,67.16,102,,,Fee Schedule,102% of CMS OPPS Rate,80.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,73.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,151.43,230,,,Fee Schedule,230% of CMS OPPS Rate,50.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,94.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,47.58,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,65.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.44,233.07,
Use of external hot or cold packs,4569829,CDM,431,RC,97010,HCPCS,Outpatient,,,62.37,37.42,,21.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,10.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,191,
OT EVAL MOD COMP 45MIN,4569830,CDM,434,RC,97166,HCPCS,Outpatient,,,262,157.2,,339.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,72.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.88,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,186.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.4,70,,,percent of total billed charges,70% of total billed charges,196.5,75,,,percent of total billed charges,75% of total billed charges,172.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.58,350,,,Fee Schedule,350% of CMS OPPS Rate,97.8,102,,,Fee Schedule,102% of CMS OPPS Rate,200.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,117.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,183.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,220.52,230,,,Fee Schedule,230% of CMS OPPS Rate,125.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,235.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,72.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,95.88,100,,,Fee Schedule,100% of CMS OPPS Rate,72.35,339.42,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",4569834,CDM,431,RC,97016,HCPCS,Outpatient,,,51.03,30.62,,39.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,35.72,70,,,percent of total billed charges,70% of total billed charges,38.27,75,,,percent of total billed charges,75% of total billed charges,20.21,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,40.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.31,350,,,Fee Schedule,350% of CMS OPPS Rate,11.45,102,,,Fee Schedule,102% of CMS OPPS Rate,39.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,35.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,25.83,230,,,Fee Schedule,230% of CMS OPPS Rate,24.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.23,100,,,Fee Schedule,100% of CMS OPPS Rate,8,191,
Use of massage,4569836,CDM,430,RC,97124,HCPCS,Outpatient,,,84,50.4,,100.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,62.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.8,70,,,percent of total billed charges,70% of total billed charges,63,75,,,percent of total billed charges,75% of total billed charges,50.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,67.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.95,350,,,Fee Schedule,350% of CMS OPPS Rate,28.84,102,,,Fee Schedule,102% of CMS OPPS Rate,64.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,50.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,58.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,65.02,230,,,Fee Schedule,230% of CMS OPPS Rate,40.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,75.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,28.27,100,,,Fee Schedule,100% of CMS OPPS Rate,13.16,191,
PARAFFIN - OT,4569838,CDM,431,RC,97018,HCPCS,Outpatient,,,41.58,24.95,,19.05,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,18.11,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.11,70,,,percent of total billed charges,70% of total billed charges,31.19,75,,,percent of total billed charges,75% of total billed charges,9.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,33.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.83,350,,,Fee Schedule,350% of CMS OPPS Rate,5.49,102,,,Fee Schedule,102% of CMS OPPS Rate,31.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,18.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,29.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,12.37,230,,,Fee Schedule,230% of CMS OPPS Rate,19.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,37.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,100,,,Fee Schedule,100% of CMS OPPS Rate,5.38,191,
Use of external hot or cold packs,4569839,CDM,431,RC,97010,HCPCS,Outpatient,,,62.37,37.42,,21.17,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,43.66,70,,,percent of total billed charges,70% of total billed charges,46.78,75,,,percent of total billed charges,75% of total billed charges,10.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.93,350,,,Fee Schedule,350% of CMS OPPS Rate,6.1,102,,,Fee Schedule,102% of CMS OPPS Rate,47.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,28.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,43.66,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,13.75,230,,,Fee Schedule,230% of CMS OPPS Rate,29.94,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,56.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5.98,191,
Light-based method to treat pain and inflammation,4569841,CDM,431,RC,97026,HCPCS,Outpatient,,,44,26.4,,22.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,30.8,70,,,percent of total billed charges,70% of total billed charges,33,75,,,percent of total billed charges,75% of total billed charges,11.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,35.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,350,,,Fee Schedule,350% of CMS OPPS Rate,6.4,102,,,Fee Schedule,102% of CMS OPPS Rate,33.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,19.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,30.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,14.42,230,,,Fee Schedule,230% of CMS OPPS Rate,21.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,39.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,191,
ORTHOTIC FITTING/TRAINING,4569842,CDM,430,RC,97760,HCPCS,Outpatient,,,141,84.6,,160.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,22.34,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,98.7,70,,,percent of total billed charges,70% of total billed charges,105.75,75,,,percent of total billed charges,75% of total billed charges,81.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,112.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.31,350,,,Fee Schedule,350% of CMS OPPS Rate,46.13,102,,,Fee Schedule,102% of CMS OPPS Rate,107.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,63.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,98.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,104.03,230,,,Fee Schedule,230% of CMS OPPS Rate,67.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,126.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.34,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,22.34,191,
EVALUATION COMPREHENSIVE,4569854,CDM,434,RC,97003,HCPCS,Outpatient,,,173.34,104,,31.2,18,,,percent of total billed charges,pays at 18% of total charges,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,86.67,50,,,percent of total billed charges,pays at 50% of total billed charges,121.34,70,,,percent of total billed charges,70% of total billed charges,130.01,75,,,percent of total billed charges,75% of total billed charges,86.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,138.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,104,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,132.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,121.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,104,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,121.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,173.34,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,156.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.16,191,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",4569857,CDM,431,RC,97035,HCPCS,Outpatient,,,42,25.2,,48.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,13.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,29.4,70,,,percent of total billed charges,70% of total billed charges,31.5,75,,,percent of total billed charges,75% of total billed charges,24.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,33.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.06,350,,,Fee Schedule,350% of CMS OPPS Rate,14,102,,,Fee Schedule,102% of CMS OPPS Rate,32.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,18.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,25.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,29.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,31.58,230,,,Fee Schedule,230% of CMS OPPS Rate,20.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,37.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,13.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6.58,191,
WHIRLPOOL - OT,4569858,CDM,431,RC,97022,HCPCS,Outpatient,,,63.45,38.07,,56.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,28.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,191,
FLUIDOTHERAPY - OT,4569859,CDM,431,RC,97022,HCPCS,Outpatient,,,63.45,38.07,,56.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,44.42,70,,,percent of total billed charges,70% of total billed charges,47.59,75,,,percent of total billed charges,75% of total billed charges,28.69,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,50.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,48.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,28.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.07,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,44.42,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,36.66,230,,,Fee Schedule,230% of CMS OPPS Rate,30.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,57.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,100,,,Fee Schedule,100% of CMS OPPS Rate,9.94,191,
SERIAL CASTING LONG ARM,4569897,CDM,430,RC,29065,HCPCS,Outpatient,,,232.68,139.61,,772.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,483.79,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,162.88,70,,,percent of total billed charges,70% of total billed charges,174.51,75,,,percent of total billed charges,75% of total billed charges,392.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.35,350,,,Fee Schedule,350% of CMS OPPS Rate,222.45,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,501.63,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.46,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,36.46,772.08,
SERIAL CASTING SHORT ARM,4569898,CDM,430,RC,29075,HCPCS,Outpatient,,,236.57,141.94,,772.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,483.79,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,165.6,70,,,percent of total billed charges,70% of total billed charges,177.43,75,,,percent of total billed charges,75% of total billed charges,392.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,189.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.35,350,,,Fee Schedule,350% of CMS OPPS Rate,222.45,103,,,Fee Schedule,103% of CMS OPPS Rate,180.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,106.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,165.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,141.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,165.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,501.63,100,,,Fee Schedule,100% of CMS OPPS Rate,113.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,212.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,37.07,772.08,
STRAPPING ANKLE AND/OR FOOT,4569901,CDM,430,RC,29540,HCPCS,Outpatient,,,112.27,67.36,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,112.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,276.11,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,78.59,70,,,percent of total billed charges,70% of total billed charges,84.2,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,112.27,103,,,Fee Schedule,103% of CMS OPPS Rate,85.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,50.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,78.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,53.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,112.27,100,,,Fee Schedule,100% of CMS OPPS Rate,101.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,17.59,469.08,
STRAPPING KNEE,4569902,CDM,430,RC,29530,HCPCS,Outpatient,,,98.26,58.96,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,68.78,70,,,percent of total billed charges,70% of total billed charges,73.7,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,98.26,103,,,Fee Schedule,103% of CMS OPPS Rate,75.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.93,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,44.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.78,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,47.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.26,100,,,Fee Schedule,100% of CMS OPPS Rate,88.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,15.4,373.66,
STRAPPING FINGER OR HAND,4569903,CDM,430,RC,29280,HCPCS,Outpatient,,,98.1,58.86,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,68.67,70,,,percent of total billed charges,70% of total billed charges,73.58,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,78.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,75.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,58.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,68.67,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,47.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,88.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,15.37,191,
STRAPPING ELBOW OR WRIST,4569904,CDM,430,RC,29260,HCPCS,Outpatient,,,103,61.8,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,72.1,70,,,percent of total billed charges,70% of total billed charges,77.25,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,78.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,17.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,46.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,72.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,49.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.14,191,
Therapy for speech or hearing,4569912,CDM,441,RC,92507,HCPCS,Outpatient,,,293,175.8,,260.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.1,70,,,percent of total billed charges,70% of total billed charges,219.75,75,,,percent of total billed charges,75% of total billed charges,132.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.25,350,,,Fee Schedule,350% of CMS OPPS Rate,74.97,102,,,Fee Schedule,102% of CMS OPPS Rate,224.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,131.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,205.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.05,230,,,Fee Schedule,230% of CMS OPPS Rate,140.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,263.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.56,263.7,
EVAL SWALLOW FUNCT EXTND 31-60 MIN,4569915,CDM,444,RC,92610,HCPCS,Outpatient,,,220,132,,239.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,121.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.5,350,,,Fee Schedule,350% of CMS OPPS Rate,68.92,102,,,Fee Schedule,102% of CMS OPPS Rate,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,155.41,230,,,Fee Schedule,230% of CMS OPPS Rate,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,37.16,239.2,
COGNITIVE TESTING PER HR,4569918,CDM,440,RC,96125,HCPCS,Outpatient,,,187.2,112.32,,347.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,244.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,131.04,70,,,percent of total billed charges,70% of total billed charges,140.4,75,,,percent of total billed charges,75% of total billed charges,176.8,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,149.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.77,350,,,Fee Schedule,350% of CMS OPPS Rate,100.18,102,,,Fee Schedule,102% of CMS OPPS Rate,143.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.25,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,84.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,112.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,131.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,225.91,230,,,Fee Schedule,230% of CMS OPPS Rate,89.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,168.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,100,,,Fee Schedule,100% of CMS OPPS Rate,29.33,347.7,
EVAL ORAL/PHARYG SWAL FUN 0-30 MIN,4569919,CDM,444,RC,92610,HCPCS,Outpatient,,,221,132.6,,239.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,37.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,154.7,70,,,percent of total billed charges,70% of total billed charges,165.75,75,,,percent of total billed charges,75% of total billed charges,121.63,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,176.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,236.5,350,,,Fee Schedule,350% of CMS OPPS Rate,68.92,102,,,Fee Schedule,102% of CMS OPPS Rate,169.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,99.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,154.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,155.41,230,,,Fee Schedule,230% of CMS OPPS Rate,106.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,198.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,67.57,100,,,Fee Schedule,100% of CMS OPPS Rate,37.16,239.2,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",4569920,CDM,420,RC,97110,HCPCS,Outpatient,,,68.4,41.04,,99.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.21,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,28.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.88,70,,,percent of total billed charges,70% of total billed charges,51.3,75,,,percent of total billed charges,75% of total billed charges,50.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,98.35,350,,,Fee Schedule,350% of CMS OPPS Rate,28.66,102,,,Fee Schedule,102% of CMS OPPS Rate,52.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,30.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,41.04,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,47.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,64.63,230,,,Fee Schedule,230% of CMS OPPS Rate,32.83,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,61.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,16.21,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,28.1,100,,,Fee Schedule,100% of CMS OPPS Rate,16.21,191,
Therapy for speech or hearing,4569922,CDM,441,RC,92507,HCPCS,Outpatient,,,233,139.8,,260.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,163.1,70,,,percent of total billed charges,70% of total billed charges,174.75,75,,,percent of total billed charges,75% of total billed charges,132.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.25,350,,,Fee Schedule,350% of CMS OPPS Rate,74.97,102,,,Fee Schedule,102% of CMS OPPS Rate,178.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,104.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,163.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,169.05,230,,,Fee Schedule,230% of CMS OPPS Rate,111.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,209.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,49.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,73.5,100,,,Fee Schedule,100% of CMS OPPS Rate,49.56,260.19,
MOTION FLUOROSCOPY EVAL,4569925,CDM,444,RC,92611,HCPCS,Outpatient,,,357,214.2,,309.36,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.36,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,87.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,180.99,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.9,70,,,percent of total billed charges,70% of total billed charges,267.75,75,,,percent of total billed charges,75% of total billed charges,157.3,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,305.87,350,,,Fee Schedule,350% of CMS OPPS Rate,89.14,102,,,Fee Schedule,102% of CMS OPPS Rate,273.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,160.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,249.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,201,230,,,Fee Schedule,230% of CMS OPPS Rate,171.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,321.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,40.36,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,100,,,Fee Schedule,100% of CMS OPPS Rate,40.36,321.3,
EVAL SPEECH DEVICE RX 30M,4569926,CDM,444,RC,92608,HCPCS,Outpatient,,,67.5,40.5,,163.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,46.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,107.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.25,70,,,percent of total billed charges,70% of total billed charges,50.63,75,,,percent of total billed charges,75% of total billed charges,83.09,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.56,350,,,Fee Schedule,350% of CMS OPPS Rate,47.08,102,,,Fee Schedule,102% of CMS OPPS Rate,51.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.63,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,30.38,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,47.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,40.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,47.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,106.17,230,,,Fee Schedule,230% of CMS OPPS Rate,32.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,46.16,100,,,Fee Schedule,100% of CMS OPPS Rate,10.58,191,
TRAIN W/ SPEECH DEVICE,4569927,CDM,441,RC,92609,HCPCS,Outpatient,,,109.35,65.61,,347.24,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,225.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.55,70,,,percent of total billed charges,70% of total billed charges,82.01,75,,,percent of total billed charges,75% of total billed charges,176.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,87.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,343.32,350,,,Fee Schedule,350% of CMS OPPS Rate,100.05,102,,,Fee Schedule,102% of CMS OPPS Rate,83.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,49.21,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,76.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,225.61,230,,,Fee Schedule,230% of CMS OPPS Rate,52.49,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,98.09,100,,,Fee Schedule,100% of CMS OPPS Rate,17.14,347.24,
SPEECH FLUENCY EVAL 0-30 MIN,4569930,CDM,444,RC,92521,HCPCS,Outpatient,,,182.07,109.24,,451.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,127.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,234.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.45,70,,,percent of total billed charges,70% of total billed charges,136.55,75,,,percent of total billed charges,75% of total billed charges,229.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.29,350,,,Fee Schedule,350% of CMS OPPS Rate,130.06,102,,,Fee Schedule,102% of CMS OPPS Rate,139.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,81.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,127.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,293.27,230,,,Fee Schedule,230% of CMS OPPS Rate,87.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,163.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,451.39,
SPEECH PRODUCTION EVAL 0-30 MIN,4569932,CDM,444,RC,92522,HCPCS,Outpatient,,,162.41,97.45,,378.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.69,70,,,percent of total billed charges,70% of total billed charges,121.81,75,,,percent of total billed charges,75% of total billed charges,192.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.36,350,,,Fee Schedule,350% of CMS OPPS Rate,109.1,102,,,Fee Schedule,102% of CMS OPPS Rate,124.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,73.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,246.01,230,,,Fee Schedule,230% of CMS OPPS Rate,77.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,146.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,378.64,
Evaluation of speech sound production with evaluation of language comprehension,4569933,CDM,444,RC,92523,HCPCS,Outpatient,,,333.9,200.34,,773.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,407.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,233.73,70,,,percent of total billed charges,70% of total billed charges,250.43,75,,,percent of total billed charges,75% of total billed charges,393.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,267.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765.1,350,,,Fee Schedule,350% of CMS OPPS Rate,222.97,102,,,Fee Schedule,102% of CMS OPPS Rate,255.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,150.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,233.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,233.73,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,502.78,230,,,Fee Schedule,230% of CMS OPPS Rate,160.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,300.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,773.84,
VOICE QUALITY EVAL 0-31 MIN,4569934,CDM,444,RC,92524,HCPCS,Outpatient,,,162.41,97.45,,374.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.69,70,,,percent of total billed charges,70% of total billed charges,121.81,75,,,percent of total billed charges,75% of total billed charges,190.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.2,350,,,Fee Schedule,350% of CMS OPPS Rate,107.89,102,,,Fee Schedule,102% of CMS OPPS Rate,124.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,73.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,243.27,230,,,Fee Schedule,230% of CMS OPPS Rate,77.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,146.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,374.43,
AUDIOMETRIC SCREENNG-ST,4569940,CDM,470,RC,92551,HCPCS,Outpatient,,,87.75,52.65,,15.8,18,,,percent of total billed charges,pays at 18% of total charges,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,43.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,100,,,Case rate,Pays based on per visit ,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,137,
EVAL SPEECH PROD EXTND 31- 60 MIN,4569942,CDM,444,RC,92522,HCPCS,Outpatient,,,272,163.2,,378.64,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,190.4,70,,,percent of total billed charges,70% of total billed charges,204,75,,,percent of total billed charges,75% of total billed charges,192.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,217.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,374.36,350,,,Fee Schedule,350% of CMS OPPS Rate,109.1,102,,,Fee Schedule,102% of CMS OPPS Rate,208.08,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,122.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,163.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,190.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,246.01,230,,,Fee Schedule,230% of CMS OPPS Rate,130.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,244.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,106.96,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,378.64,
Evaluation of speech sound production with evaluation of language comprehension,4569943,CDM,444,RC,92523,HCPCS,Outpatient,,,567,340.2,,773.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,407.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,396.9,70,,,percent of total billed charges,70% of total billed charges,425.25,75,,,percent of total billed charges,75% of total billed charges,393.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,453.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,765.1,350,,,Fee Schedule,350% of CMS OPPS Rate,222.97,102,,,Fee Schedule,102% of CMS OPPS Rate,433.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,255.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,396.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,340.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,396.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,502.78,230,,,Fee Schedule,230% of CMS OPPS Rate,272.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,510.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,218.6,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,773.84,
EVAL VOICE QUALITY EXTND 31- 60 MIN,4569944,CDM,444,RC,92524,HCPCS,Outpatient,,,266,159.6,,374.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,186.2,70,,,percent of total billed charges,70% of total billed charges,199.5,75,,,percent of total billed charges,75% of total billed charges,190.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,212.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,370.2,350,,,Fee Schedule,350% of CMS OPPS Rate,107.89,102,,,Fee Schedule,102% of CMS OPPS Rate,203.49,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,119.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,186.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,243.27,230,,,Fee Schedule,230% of CMS OPPS Rate,127.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,239.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,374.43,
EVAL SPEECH FLUENCY EXTND 31-60 MIN,4569950,CDM,444,RC,92521,HCPCS,Outpatient,,,182.07,109.24,,451.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,66.74,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,127.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,234.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.45,70,,,percent of total billed charges,70% of total billed charges,136.55,75,,,percent of total billed charges,75% of total billed charges,229.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.29,350,,,Fee Schedule,350% of CMS OPPS Rate,130.06,102,,,Fee Schedule,102% of CMS OPPS Rate,139.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,81.93,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,127.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,293.27,230,,,Fee Schedule,230% of CMS OPPS Rate,87.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,163.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,66.74,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,127.51,100,,,Fee Schedule,100% of CMS OPPS Rate,66.74,451.39,
FEES SWALLOW EVAL,4569955,CDM,444,RC,92612,HCPCS,Outpatient,,,162,97.2,,227.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,154.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,141.6,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,113.4,70,,,percent of total billed charges,70% of total billed charges,121.5,75,,,percent of total billed charges,75% of total billed charges,115.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,129.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,225.26,350,,,Fee Schedule,350% of CMS OPPS Rate,65.65,102,,,Fee Schedule,102% of CMS OPPS Rate,123.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,72.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,113.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,148.03,230,,,Fee Schedule,230% of CMS OPPS Rate,77.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,145.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,154.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,100,,,Fee Schedule,100% of CMS OPPS Rate,64.36,227.83,
DYSPHAGIA TREATMENT 31-60 MIN,4569988,CDM,440,RC,92526,HCPCS,Outpatient,,,256,153.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.12,287.06,
DYSPHAGIA TREATMENT 0- 30 MIN,4569998,CDM,440,RC,92526,HCPCS,Outpatient,,,256,153.6,,287.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,81.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,179.2,70,,,percent of total billed charges,70% of total billed charges,192,75,,,percent of total billed charges,75% of total billed charges,145.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,283.82,350,,,Fee Schedule,350% of CMS OPPS Rate,82.71,102,,,Fee Schedule,102% of CMS OPPS Rate,195.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.11,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,115.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,179.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,186.51,230,,,Fee Schedule,230% of CMS OPPS Rate,122.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.12,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,81.09,100,,,Fee Schedule,100% of CMS OPPS Rate,40.12,287.06,
MED NUTR THERAPY SCREEN,5510600,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRI THREAPY LIMITED,5510998,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRITION THRPY I .25,5511000,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRITION THRPY I .50,5511002,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRITION THRPY I .75,5511004,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRITION THRPY I 1.0,5511006,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRITION THRPY F/U.50,5511008,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
INTK ANAL LIM 15,5512000,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
MED NUTRITION THRPY OP.75,5517004,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
III MED NUTR THERAPY SCRN,5517008,CDM,942,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,191,
OUT PT ED 2.0,5519000,CDM,942,RC,97802,HCPCS,Outpatient,,,72.55,43.53,,109.07,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,30.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,50.79,70,,,percent of total billed charges,70% of total billed charges,54.41,75,,,percent of total billed charges,75% of total billed charges,55.46,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,58.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.84,350,,,Fee Schedule,350% of CMS OPPS Rate,31.43,102,,,Fee Schedule,102% of CMS OPPS Rate,55.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,32.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.53,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,191,100,,,Case rate,Pays based on per visit ,50.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,70.86,230,,,Fee Schedule,230% of CMS OPPS Rate,34.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,65.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,100,,,Fee Schedule,100% of CMS OPPS Rate,11.37,191,
OXYGEN UPTAKE,5519100,CDM,460,RC,94690,HCPCS,Outpatient,,,108.8,65.28,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,64.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,76.16,70,,,percent of total billed charges,70% of total billed charges,81.6,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,87.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,83.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,48.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,76.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,65.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,76.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,52.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,97.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,17.05,422,
Ultrasound of single fetus,5526711,CDM,402,RC,76811,HCPCS,Outpatient,,,588,352.8,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,411.6,70,,,percent of total billed charges,70% of total billed charges,441,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,470.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,449.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,101.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,411.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,352.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,411.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,282.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,529.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,92.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,92.14,751.51,
Transvaginal ultrasound of uterus,5526717,CDM,402,RC,76817,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
Fetal biophysical profile without non-stress test,5526719,CDM,402,RC,76819,HCPCS,Outpatient,,,322.92,193.75,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,226.04,70,,,percent of total billed charges,70% of total billed charges,242.19,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,258.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,247.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,145.31,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,193.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,226.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,155,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,290.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,50.6,446,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,5526801,CDM,402,RC,76801,HCPCS,Outpatient,,,414.9,248.94,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,290.43,70,,,percent of total billed charges,70% of total billed charges,311.18,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,331.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,317.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,186.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,290.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,248.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,290.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,199.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,373.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.01,446,
US OB <14 WKS/ADD FETUS,5526802,CDM,402,RC,76802,HCPCS,Outpatient,,,290.25,174.15,,52.25,18,,,percent of total billed charges,pays at 18% of total charges,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.18,70,,,percent of total billed charges,70% of total billed charges,217.69,75,,,percent of total billed charges,75% of total billed charges,145.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,232.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,174.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,222.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.01,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.61,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,203.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.15,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,203.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,290.25,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,261.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.48,446,
US OB DETAILED/ADD FETUS,5526812,CDM,402,RC,76812,HCPCS,Outpatient,,,161,96.6,,28.98,18,,,percent of total billed charges,pays at 18% of total charges,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.98,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.7,70,,,percent of total billed charges,70% of total billed charges,120.75,75,,,percent of total billed charges,75% of total billed charges,80.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.74,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,112.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.23,446,
Ultrasound of fetus with limited views,5526816,CDM,402,RC,76815,HCPCS,Outpatient,,,311.4,186.84,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,217.98,70,,,percent of total billed charges,70% of total billed charges,233.55,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,249.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,238.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,217.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,149.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,280.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.8,446,
OB US FOLLOW-UP PER FETUS,5526817,CDM,402,RC,76816,HCPCS,Outpatient,,,271.44,162.86,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,190.01,70,,,percent of total billed charges,70% of total billed charges,203.58,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,217.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,207.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,122.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,190.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.86,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,190.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,130.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,244.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,42.53,446,
UMBILICAL ARTERY ECHO,5526821,CDM,402,RC,76820,HCPCS,Outpatient,,,553.52,332.11,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,387.46,70,,,percent of total billed charges,70% of total billed charges,415.14,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,442.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,423.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,95.37,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,249.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,387.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,332.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,387.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,265.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,498.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,86.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,86.74,498.17,
MIDDLE CEREBRAL ARTERY ECHO,5526822,CDM,402,RC,76821,HCPCS,Outpatient,,,278,166.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,194.6,70,,,percent of total billed charges,70% of total billed charges,208.5,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,222.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,212.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,125.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,194.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,133.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,250.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,43.56,446,
US FETAL DOPPLER/COND/MCA,5526827,CDM,402,RC,76827,HCPCS,Outpatient,,,,,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,446,
US GUIDE FOR AMNIO(PERIN),5526947,CDM,402,RC,76946,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446,446,
EXTERNAL CEPHALIC VERSION,5529412,CDM,320,RC,59412,HCPCS,Outpatient,,,,,,9099.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4541.26,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4626.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,8996.49,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5911.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2570.42,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9099.29,
FOGARTY OVER WIRE,5540002,CDM,272,RC,C1757,HCPCS,Outpatient,,,203.5,122.1,,36.63,18,,,percent of total billed charges,pays at 18% of total charges,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36.63,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.45,70,,,percent of total billed charges,70% of total billed charges,152.63,75,,,percent of total billed charges,75% of total billed charges,101.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,162.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,155.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,122.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,77.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,203.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,183.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.89,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.89,203.5,
CATH HEMO DYAL SHORT TERM,5540007,CDM,278,RC,C1752,HCPCS,Outpatient,,,223.5,134.1,,40.23,18,,,percent of total billed charges,pays at 18% of total charges,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.45,70,,,percent of total billed charges,70% of total billed charges,167.63,75,,,percent of total billed charges,75% of total billed charges,111.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.02,223.5,
ATD AMPLATZ THROM DEVICE,5540010,CDM,272,RC,C1757,HCPCS,Outpatient,,,1284,770.4,,231.12,18,,,percent of total billed charges,pays at 18% of total charges,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,231.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.8,70,,,percent of total billed charges,70% of total billed charges,963,75,,,percent of total billed charges,75% of total billed charges,642,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1027.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,770.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,982.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,221.23,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,898.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,770.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,487.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,898.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1284,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1155.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,201.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.2,1284,
BILIARY STENT TRANSHEPATIC,5540013,CDM,278,RC,C1876,HCPCS,Outpatient,,,3201.5,1920.9,,576.27,18,,,percent of total billed charges,pays at 18% of total charges,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,576.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2241.05,70,,,percent of total billed charges,70% of total billed charges,2401.13,75,,,percent of total billed charges,75% of total billed charges,1600.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2561.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3201.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,551.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2241.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1216.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2241.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.68,3201.5,
WALLSTENT UNISTEP PLUS,5540015,CDM,278,RC,C1876,HCPCS,Outpatient,,,2881,1728.6,,518.58,18,,,percent of total billed charges,pays at 18% of total charges,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,518.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2016.7,70,,,percent of total billed charges,70% of total billed charges,2160.75,75,,,percent of total billed charges,75% of total billed charges,1440.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2304.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1728.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2881,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,496.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1296.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2016.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1728.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1094.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2016.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1382.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2881,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2881,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,451.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.45,2881,
CATHETER REPAIR KIT,5540016,CDM,272,RC,,,Outpatient,,,400,240,,72,18,,,percent of total billed charges,pays at 18% of total charges,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200,50,,,percent of total billed charges,pays at 50% of total billed charges,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.68,400,
PERI-RENAL DRAINAGE,5540021,CDM,360,RC,50020,HCPCS,Outpatient,,,2160,1296,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5498.42,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1512,70,,,percent of total billed charges,70% of total billed charges,1620,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1728,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1652.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,972,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1296,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1512,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1944,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,972,5969.39,
INTRODUCER - LABS 200,5540029,CDM,272,RC,C1894,HCPCS,Outpatient,,,805.5,483.3,,144.99,18,,,percent of total billed charges,pays at 18% of total charges,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,144.99,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.85,70,,,percent of total billed charges,70% of total billed charges,604.13,75,,,percent of total billed charges,75% of total billed charges,402.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,644.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,483.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,616.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,138.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,563.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,483.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,563.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,805.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,724.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,126.22,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.22,805.5,
GUIDE CATH - LABS 200,5540030,CDM,272,RC,C1887,HCPCS,Outpatient,,,269,161.4,,48.42,18,,,percent of total billed charges,pays at 18% of total charges,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.75,75,,,percent of total billed charges,75% of total billed charges,134.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,215.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,205.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,46.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,102.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,269,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,242.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,42.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.15,269,
CATH HEMODIALY LONG-TERM,5540031,CDM,278,RC,C1750,HCPCS,Outpatient,,,633,379.8,,113.94,18,,,percent of total billed charges,pays at 18% of total charges,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,113.94,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.1,70,,,percent of total billed charges,70% of total billed charges,474.75,75,,,percent of total billed charges,75% of total billed charges,316.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,506.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,379.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,109.07,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,443.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,379.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,240.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,443.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,633,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,633,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,99.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.19,633,
NERVE BLOCK CERV.,5540032,CDM,360,RC,64490,HCPCS,Outpatient,,,1200,720,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,2742.49,
NERVE BLOCK CERV ADDL LVL,5540033,CDM,360,RC,64491,HCPCS,Outpatient,,,1200,720,,216,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,216,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,1200,
Injection into lower back of nerve block using imaging guidance,5540034,CDM,360,RC,64493,HCPCS,Outpatient,,,1200,720,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,2742.49,
NERVE BLOCK LUMB ADDL LVL,5540035,CDM,360,RC,64494,HCPCS,Outpatient,,,400,240,,72,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,657,
EPIDURAL INJECTION CERV,5540036,CDM,360,RC,64479,HCPCS,Outpatient,,,1200,720,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,2742.49,
EPIDURAL INJ / ADD LEVEL,5540037,CDM,360,RC,64480,HCPCS,Outpatient,,,480,288,,86.4,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,86.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,70,,,percent of total billed charges,70% of total billed charges,360,75,,,percent of total billed charges,75% of total billed charges,240,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,367.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,336,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,480,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,432,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,657,
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,5540038,CDM,360,RC,64483,HCPCS,Outpatient,,,1200,720,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,540,2742.49,
EPIDURAL INJECT. LUMB ADD,5540039,CDM,360,RC,64484,HCPCS,Outpatient,,,1200,720,,216,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,216,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,600,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216,1200,
SYMPATHETIC NERVE BLOCK,5540040,CDM,360,RC,64520,HCPCS,Outpatient,,,813.6,488.16,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,569.52,70,,,percent of total billed charges,70% of total billed charges,610.2,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,650.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,622.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,366.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,569.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,488.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,569.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,390.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,732.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,366.12,2742.49,
DEST. NERVE LUMB,5540041,CDM,360,RC,64635,HCPCS,Outpatient,,,1662.84,997.7,,5784.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1634.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1634.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3283.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1163.99,70,,,percent of total billed charges,70% of total billed charges,1247.13,75,,,percent of total billed charges,75% of total billed charges,2941.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1330.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5719.43,350,,,Fee Schedule,350% of CMS OPPS Rate,1662.84,103,,,Fee Schedule,103% of CMS OPPS Rate,1272.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,748.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1163.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,997.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1163.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,3758.48,100,,,Fee Schedule,100% of CMS OPPS Rate,798.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1496.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,748.28,5784.8,
DEST. NERVE LUMB ADD LVL,5540042,CDM,360,RC,64636,HCPCS,Outpatient,,,400,240,,72,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,657,
DEST. NERVE CERT/THORACIC,5540043,CDM,360,RC,64633,HCPCS,Outpatient,,,7451.6,4470.96,,5784.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1634.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1634.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3217.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,5216.12,70,,,percent of total billed charges,70% of total billed charges,5588.7,75,,,percent of total billed charges,75% of total billed charges,2941.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5961.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5719.43,350,,,Fee Schedule,350% of CMS OPPS Rate,1666.8,103,,,Fee Schedule,103% of CMS OPPS Rate,5700.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,3353.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,5216.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4470.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,5216.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,3758.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3576.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,6706.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.12,6706.44,
DEST. NERVE ADD CERV/THOR,5540044,CDM,360,RC,64634,HCPCS,Outpatient,,,481.2,288.72,,86.62,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,86.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.84,70,,,percent of total billed charges,70% of total billed charges,360.9,75,,,percent of total billed charges,75% of total billed charges,240.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,384.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,288.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,368.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,336.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,288.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,336.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.98,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,481.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,433.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.62,657,
DEST. NERVE CELIAC PLEXUS,5540045,CDM,360,RC,64680,HCPCS,Outpatient,,,1629.6,977.76,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1140.72,70,,,percent of total billed charges,70% of total billed charges,1222.2,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1303.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,1246.64,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,733.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1140.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,977.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1140.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,782.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1466.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,733.32,2742.49,
CATH HEMODIALY LONG TERM,5540046,CDM,278,RC,C1750,HCPCS,Outpatient,,,662.5,397.5,,119.25,18,,,percent of total billed charges,pays at 18% of total charges,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.75,70,,,percent of total billed charges,70% of total billed charges,496.88,75,,,percent of total billed charges,75% of total billed charges,331.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,530,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.81,662.5,
TREROTOLA BASKET,5540047,CDM,272,RC,C1757,HCPCS,Outpatient,,,828.5,497.1,,149.13,18,,,percent of total billed charges,pays at 18% of total charges,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,149.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.95,70,,,percent of total billed charges,70% of total billed charges,621.38,75,,,percent of total billed charges,75% of total billed charges,414.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,662.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,497.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,633.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,142.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,579.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,497.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,314.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,579.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,828.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,745.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.83,828.5,
TREROTOLA ROTATOR,5540048,CDM,272,RC,C1757,HCPCS,Outpatient,,,191,114.6,,34.38,18,,,percent of total billed charges,pays at 18% of total charges,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.7,70,,,percent of total billed charges,70% of total billed charges,143.25,75,,,percent of total billed charges,75% of total billed charges,95.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,152.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.91,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,133.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,114.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,72.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,133.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,191,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,171.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.93,191,
"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",5540050,CDM,360,RC,10005,HCPCS,Outpatient,,,713.6,428.16,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1181.22,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,499.52,70,,,percent of total billed charges,70% of total billed charges,535.2,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,570.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,545.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,321.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,499.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,428.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,499.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,342.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,642.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,321.12,2088.52,
NEEDLE BX LYMPH NODE,5540052,CDM,360,RC,38505,HCPCS,Outpatient,,,3715,2229,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges,2786.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2972,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2841.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2229,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2600.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1783.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,4825.85,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",5540053,CDM,360,RC,10160,HCPCS,Outpatient,,,402.16,241.3,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,281.51,70,,,percent of total billed charges,70% of total billed charges,301.62,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,307.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,180.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,361.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,180.97,1200.6,
BX TRAY,5540053E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
NEEDLE-PERCUT-195326,5540053E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
US GUIDED NDLE PLACEMENT,5540053E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",5540053E,CDM,360,RC,10160,HCPCS,Outpatient,,,402.16,241.3,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,281.51,70,,,percent of total billed charges,70% of total billed charges,301.62,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,307.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,180.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,361.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,180.97,1200.6,
Incision and drainage of abscess; simple or single and complex or multiple,5540060,CDM,360,RC,10060,HCPCS,Outpatient,,,297.44,178.46,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,208.21,70,,,percent of total billed charges,70% of total billed charges,223.08,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,657,
PLATINUM PLUS GUIDEWIRES,5540066,CDM,621,RC,C1769,HCPCS,Outpatient,,,296,177.6,,53.28,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,53.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222,75,,,percent of total billed charges,75% of total billed charges,148,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,236.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,177.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,226.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,177.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,112.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,207.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,296,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,266.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.28,296,
GLIDEWIRE GOLD,5540068,CDM,272,RC,C1769,HCPCS,Outpatient,,,445,267,,80.1,18,,,percent of total billed charges,pays at 18% of total charges,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,80.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.75,75,,,percent of total billed charges,75% of total billed charges,222.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,356,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,267,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,340.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,76.67,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,311.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,267,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,169.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,311.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,445,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,400.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.73,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.73,445,
PER THYROID CORE BX,5540100,CDM,360,RC,60100,HCPCS,Outpatient,,,568.8,341.28,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,568.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,398.16,70,,,percent of total billed charges,70% of total billed charges,426.6,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,455.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,568.8,103,,,Fee Schedule,103% of CMS OPPS Rate,435.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,255.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,398.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,341.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,398.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,273.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,568.8,100,,,Fee Schedule,100% of CMS OPPS Rate,511.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,255.96,2088.52,
REMOVAL OF FB SUBCUTANEOUS,5540120,CDM,360,RC,10120,HCPCS,Outpatient,,,626,375.6,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,438.2,70,,,percent of total billed charges,70% of total billed charges,469.5,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,500.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,478.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,281.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,375.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,438.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,300.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,563.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,281.7,1200.6,
BX RENAL,5540200,CDM,360,RC,50200,HCPCS,Outpatient,,,1600,960,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,4825.85,
BIOPSY NEEDLES,5540200E,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
BX TRAY,5540200E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
BX RENAL,5540200E,CDM,360,RC,50200,HCPCS,Outpatient,,,1600,960,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,4825.85,
US GUIDED NDLE PLACEMENT,5540200E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
SACROPLASTY BILAT,5540201,CDM,761,RC,0201T,HCPCS,Outpatient,,,14184,8510.4,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,10638,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10850.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2443.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6382.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8510.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5389.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6808.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12765.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2222.63,21287.29,
SACROPLASTY UNILAT,5540202,CDM,761,RC,0200T,HCPCS,Outpatient,,,14184,8510.4,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,10638,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11347.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,10850.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2443.9,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6382.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8510.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5389.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,9928.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6808.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,12765.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2222.63,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2222.63,21287.29,
MUSCLE BX PERC NDL,5540206,CDM,360,RC,20206,HCPCS,Outpatient,,,924,554.4,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,924,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,646.8,70,,,percent of total billed charges,70% of total billed charges,693,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,739.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,924,103,,,Fee Schedule,103% of CMS OPPS Rate,706.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,415.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,646.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,554.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,646.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,443.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,924,100,,,Fee Schedule,100% of CMS OPPS Rate,831.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,415.8,4825.85,
BIOPSY NEEDLES,5540206E,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
BX TRAY,5540206E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
US GUIDED NDLE PLACEMENT,5540206E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
MUSCLE BX PERC NDL,5540206E,CDM,360,RC,20206,HCPCS,Outpatient,,,924,554.4,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,924,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,646.8,70,,,percent of total billed charges,70% of total billed charges,693,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,739.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,924,103,,,Fee Schedule,103% of CMS OPPS Rate,706.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,415.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,646.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,554.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,646.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,443.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,924,100,,,Fee Schedule,100% of CMS OPPS Rate,831.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,415.8,4825.85,
BONE BX SUPERFCL TROCAR OR NDL,5540220,CDM,360,RC,20220,HCPCS,Outpatient,,,842.4,505.44,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,842.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2748.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,589.68,70,,,percent of total billed charges,70% of total billed charges,631.8,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,673.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,842.4,103,,,Fee Schedule,103% of CMS OPPS Rate,644.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,379.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,589.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,505.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,589.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,404.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,842.4,100,,,Fee Schedule,100% of CMS OPPS Rate,758.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,379.08,4825.85,
BONE BX DEEP TROCAR OR NDL,5540225,CDM,360,RC,20225,HCPCS,Outpatient,,,1936,1161.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1355.2,70,,,percent of total billed charges,70% of total billed charges,1452,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1548.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1481.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,871.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1355.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1161.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1355.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,929.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,871.2,4825.85,
REMOVE NEPH TUBE UNDER FLUORO,5540389,CDM,360,RC,50389,HCPCS,Outpatient,,,817.6,490.56,,2012.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,568.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,568.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1153.2,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,572.32,70,,,percent of total billed charges,70% of total billed charges,613.2,75,,,percent of total billed charges,75% of total billed charges,1023.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,654.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1989.73,350,,,Fee Schedule,350% of CMS OPPS Rate,579.86,103,,,Fee Schedule,103% of CMS OPPS Rate,625.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,367.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,572.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,490.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,572.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1307.54,100,,,Fee Schedule,100% of CMS OPPS Rate,392.45,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,735.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,367.92,2012.47,
RENAL CYST ASPIRATION,5540391,CDM,360,RC,50390,HCPCS,Outpatient,,,1746,1047.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,2088.52,
RENAL CYST ASPIRATION,5540391T,CDM,360,RC,50390,HCPCS,Outpatient,,,1746,1047.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1222.2,70,,,percent of total billed charges,70% of total billed charges,1309.5,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1396.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1335.69,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,785.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1047.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1222.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,838.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,2088.52,
RENAL PELVIS INJECT,5540392,CDM,360,RC,50432,HCPCS,Outpatient,,,2520,1512,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2316.41,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1764,70,,,percent of total billed charges,70% of total billed charges,1890,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1764,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1512,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1764,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2268,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,5969.39,
ANGIO PACK,5540392E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
GUIDEWIRES,5540392E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
GLIDEWIRES,5540392E,CDM,272,RC,C1769,HCPCS,Outpatient,,,169,101.4,,30.42,18,,,percent of total billed charges,pays at 18% of total charges,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,75,,,percent of total billed charges,75% of total billed charges,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
DRAIN POUCH NBPS-100,5540392E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
PERCUTAN SET N-PAS-100,5540392E,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
BAG DECANTER,5540392E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
FLEXIMA NEPHROSTOMY CATH,5540392E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
RENAL PELVIS INJECT,5540392E,CDM,360,RC,50432,HCPCS,Outpatient,,,2520,1512,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2316.41,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1764,70,,,percent of total billed charges,70% of total billed charges,1890,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1764,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1512,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1764,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2268,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,5969.39,
PERC DR OR STENT URETER,5540393,CDM,360,RC,50693,HCPCS,Outpatient,,,2613.6,1568.16,,10314.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2913.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2613.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5168.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1829.52,70,,,percent of total billed charges,70% of total billed charges,1960.2,75,,,percent of total billed charges,75% of total billed charges,5244.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2090.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10198.2,350,,,Fee Schedule,350% of CMS OPPS Rate,2613.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1999.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1829.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1829.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6701.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1254.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2613.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2352.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.12,10314.75,
NEPHROSTOGRAM,5540394,CDM,360,RC,50431,HCPCS,Outpatient,,,152,91.2,,2012.47,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,568.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,152,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1153.2,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,106.4,70,,,percent of total billed charges,70% of total billed charges,114,75,,,percent of total billed charges,75% of total billed charges,1023.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1989.73,350,,,Fee Schedule,350% of CMS OPPS Rate,152,103,,,Fee Schedule,103% of CMS OPPS Rate,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,1307.54,100,,,Fee Schedule,100% of CMS OPPS Rate,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,Fee Schedule,100% of CMS OPPS Rate,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,68.4,2012.47,
INTRO GUIDE URETER,5540395,CDM,360,RC,50688,HCPCS,Outpatient,,,2400,1440,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3457.32,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1680,70,,,percent of total billed charges,70% of total billed charges,1800,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1920,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1836,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1440,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1680,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,2160,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,5969.39,
PTA AV GRAFT,5540396,CDM,360,RC,36902,HCPCS,Outpatient,,,6250,3750,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10160.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4375,70,,,percent of total billed charges,70% of total billed charges,4687.5,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,4781.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2812.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4375,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3750,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4375,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,5625,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2812.5,16784.25,
NEPH TUBE CHANGE,5540398,CDM,360,RC,50435,HCPCS,Outpatient,,,1946.56,1167.94,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3388.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1362.59,70,,,percent of total billed charges,70% of total billed charges,1459.92,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1557.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1489.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,875.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1362.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1167.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1362.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,934.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,875.95,5969.39,
DRAIN POUCH NBPS-100,5540398E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
GUIDEWIRES,5540398E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
ANGIO PACK,5540398E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
FLEXIMA NEPHROSTOMY CATH,5540398E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
CHG DRAINAGE CATH,5540398E,CDM,360,RC,75984,HCPCS,Outpatient,,,319,191.4,,57.42,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,57.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.3,70,,,percent of total billed charges,70% of total billed charges,239.25,75,,,percent of total billed charges,75% of total billed charges,159.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,223.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,223.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,319,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,287.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.42,319,
NEPH TUBE CHANGE,5540398E,CDM,360,RC,50435,HCPCS,Outpatient,,,1946.56,1167.94,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3388.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1362.59,70,,,percent of total billed charges,70% of total billed charges,1459.92,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1557.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1489.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,875.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1362.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1167.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1362.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,934.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,875.95,5969.39,
FISTULA/SINUS TRACT THERAPEUTIC INJ,5540500,CDM,360,RC,20500,HCPCS,Outpatient,,,894.04,536.42,,4467.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1261.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,894.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2320.64,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,625.83,70,,,percent of total billed charges,70% of total billed charges,670.53,75,,,percent of total billed charges,75% of total billed charges,2271.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,715.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4416.85,350,,,Fee Schedule,350% of CMS OPPS Rate,894.04,103,,,Fee Schedule,103% of CMS OPPS Rate,683.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,402.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,625.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,536.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,625.83,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.5,100,,,Fee Schedule,100% of CMS OPPS Rate,429.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,894.04,100,,,Fee Schedule,100% of CMS OPPS Rate,804.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.95,100,,,Fee Schedule,100% of CMS OPPS Rate,402.32,4467.32,
FISTULA/SINUS TRACT,5540501,CDM,360,RC,20501,HCPCS,Outpatient,,,165.44,99.26,,29.78,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,29.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,115.81,70,,,percent of total billed charges,70% of total billed charges,124.08,75,,,percent of total billed charges,75% of total billed charges,82.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,132.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,126.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,115.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,165.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,148.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.78,657,
REMOVAL OF FB MUSCLE SIMPLE,5540520,CDM,360,RC,20520,HCPCS,Outpatient,,,3185,1911,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2748.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2229.5,70,,,percent of total billed charges,70% of total billed charges,2388.75,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2436.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1433.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2229.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1911,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2229.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2866.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4825.85,
REMOVAL OF FB MUSCLE  DEEP,5540525,CDM,360,RC,20525,HCPCS,Outpatient,,,5365,3219,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4455.77,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3755.5,70,,,percent of total billed charges,70% of total billed charges,4023.75,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4292,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2395.39,103,,,Fee Schedule,103% of CMS OPPS Rate,4104.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2414.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3755.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3755.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,2575.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,4828.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,8313.44,
Injection of medication into a tendon or ligament,5540550,CDM,360,RC,20550,HCPCS,Outpatient,,,397.38,238.43,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,278.17,70,,,percent of total billed charges,70% of total billed charges,298.04,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,304,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,875,
Draining or injecting medication into a small joint/bursa without ultrasound,5540605,CDM,360,RC,20600,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a major joint/bursa without ultrasound,5540610,CDM,360,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Draining or injecting medication into a major joint/bursa without ultrasound,554-0610,CDM,322,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
ARTHROCENTESIS MJT W/US,5540611,CDM,360,RC,20611,HCPCS,Outpatient,,,717,430.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,501.9,70,,,percent of total billed charges,70% of total billed charges,537.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,573.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,548.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,322.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,501.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,344.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,645.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
Removal of fluid or injection of medication into a ganglion cyst,5540612,CDM,320,RC,20612,HCPCS,Outpatient,,,397.38,238.43,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,397.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,278.17,70,,,percent of total billed charges,70% of total billed charges,298.04,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,304,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,875,
RF ABLATION BONE TUMOR,5540982,CDM,360,RC,20982,HCPCS,Outpatient,,,13007,7804.2,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11430.93,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2385,21287.29,
SUPRA PUBIC CATH BLADDER,5541010,CDM,360,RC,51102,HCPCS,Outpatient,,,3500,2100,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3388.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2450,70,,,percent of total billed charges,70% of total billed charges,2625,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2800,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,2677.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1575,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2450,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2100,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2450,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1680,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3150,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1575,5969.39,
DRAIN PLCMT IN MUSCLE/ SOFT TISSUE,5541030,CDM,360,RC,10030,HCPCS,Outpatient,,,735.05,441.03,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,514.54,70,,,percent of total billed charges,70% of total billed charges,551.29,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,588.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,562.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,514.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,514.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,352.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,661.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.77,2088.52,
GUIDEWIRES,5541030E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
DRAIN POUCH NBPS-100,5541030E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
NEEDLE-PERCUT-195326,5541030E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
BX TRAY,5541030E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLEXIMA NEPHROSTOMY CATH,5541030E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
US GUIDED NDLE PLACEMENT,5541030E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
DRAIN PLCMT IN MUSCLE/ SOFT TISSUE,5541030E,CDM,360,RC,10030,HCPCS,Outpatient,,,735.05,441.03,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,514.54,70,,,percent of total billed charges,70% of total billed charges,551.29,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,588.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,562.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,514.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,441.03,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,514.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,352.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,661.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.77,2088.52,
INSERT TEMP BLADDER CATH CMPLCTD,5541703,CDM,360,RC,51703,HCPCS,Outpatient,,,460,276,,468.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.94,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,322,70,,,percent of total billed charges,70% of total billed charges,345,75,,,percent of total billed charges,75% of total billed charges,237.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,368,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,462.73,350,,,Fee Schedule,350% of CMS OPPS Rate,134.84,103,,,Fee Schedule,103% of CMS OPPS Rate,351.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,207,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,322,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,276,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,322,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,220.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,414,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,100,,,Fee Schedule,100% of CMS OPPS Rate,132.21,657,
THORACENTESIS W/O,5542000,CDM,360,RC,32555,HCPCS,Outpatient,,,840,504,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,588,70,,,percent of total billed charges,70% of total billed charges,630,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,642.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,378,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,504,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,403.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,756,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,378,1861.73,
BX TRAY,5542000E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
THORACENTESIS W/O,5542000E,CDM,360,RC,32555,HCPCS,Outpatient,,,840,504,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,588,70,,,percent of total billed charges,70% of total billed charges,630,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,672,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,642.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,378,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,504,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,588,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,403.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,756,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,378,1861.73,
THORACENTESIS W INS TUBE,5542002,CDM,360,RC,32557,HCPCS,Outpatient,,,1008,604.8,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1008,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges,756,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,806.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1008,103,,,Fee Schedule,103% of CMS OPPS Rate,771.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,604.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,483.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1008,100,,,Fee Schedule,100% of CMS OPPS Rate,907.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,4788.21,
ANGIO PACK,5542002E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
FLUORO GUIDANCE,5542002E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
THORACENTESIS W INS TUBE,5542002E,CDM,360,RC,32557,HCPCS,Outpatient,,,1008,604.8,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1008,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges,756,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,806.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1008,103,,,Fee Schedule,103% of CMS OPPS Rate,771.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,604.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,483.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1008,100,,,Fee Schedule,100% of CMS OPPS Rate,907.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,4788.21,
CHEST TUBE PLACEMENT LEFT,5542020,CDM,360,RC,32557,HCPCS,Outpatient,,,2173.6,1304.16,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges,1630.2,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1738.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1662.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,978.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
CHEST TUBE PLACEMENT LEFT,5542020,CDM,360,RC,32557,HCPCS,Outpatient,,,,,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
GUIDEWIRES,5542020E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
NEEDLE-PERCUT-195326,5542020E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
FLEXIMA NEPHROSTOMY CATH,5542020E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
CHEST TUBE PLACEMENT LEFT,5542020E,CDM,360,RC,32557,HCPCS,Outpatient,,,2173.6,1304.16,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges,1630.2,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1738.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1662.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,978.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
CHEST TUBE PLACEMENT RIGHT,5542020RT,CDM,360,RC,32557,HCPCS,Outpatient,,,2173.6,1304.16,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges,1630.2,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1738.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1662.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,978.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
CHEST TUBE PLACEMENT RIGHT,5542020RT,CDM,360,RC,32557,HCPCS,Outpatient,,,,,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
COONS DILATORS,5542020RTE,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
NEEDLE-PERCUT-195326,5542020RTE,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
GUIDEWIRES,5542020RTE,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
FLEXIMA NEPHROSTOMY CATH,5542020RTE,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
US GUIDED NDLE PLACEMENT,5542020RTE,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
CHEST TUBE PLACEMENT RIGHT,5542020RTE,CDM,360,RC,32557,HCPCS,Outpatient,,,2173.6,1304.16,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges,1630.2,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1738.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1662.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,978.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1521.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
EMBOLIZATION COIL,5542156,CDM,278,RC,,,Outpatient,,,982.5,589.5,,176.85,18,,,percent of total billed charges,pays at 18% of total charges,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,176.85,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,491.25,50,,,percent of total billed charges,pays at 50% of total billed charges,687.75,70,,,percent of total billed charges,70% of total billed charges,736.88,75,,,percent of total billed charges,75% of total billed charges,491.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,786,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,982.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,687.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,373.35,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,687.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,982.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,982.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,153.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.96,982.5,
PERC ASP INTERVERT DISC,5542267,CDM,360,RC,62267,HCPCS,Outpatient,,,525,315,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,367.5,70,,,percent of total billed charges,70% of total billed charges,393.75,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,525,103,,,Fee Schedule,103% of CMS OPPS Rate,401.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,252,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,2088.52,
LUMBAR PUNCTURE,5542270,CDM,360,RC,62270,HCPCS,Outpatient,,,960,576,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,672,70,,,percent of total billed charges,70% of total billed charges,720,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,768,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,734.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,432,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,576,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,672,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,460.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,864,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,432,2073.62,
CERV/THORACIC  EPIDRL/SUBARACH INJ,5542310,CDM,360,RC,62321,HCPCS,Outpatient,,,1260,756,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges,945,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,963.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,567,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,604.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,567,2073.62,
BX TRAY,5542310E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
CERV/THORACIC  EPIDRL/SUBARACH INJ,5542310E,CDM,360,RC,62321,HCPCS,Outpatient,,,1260,756,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges,945,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,963.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,567,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,604.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,567,2073.62,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,5542311,CDM,360,RC,62323,HCPCS,Outpatient,,,1008,604.8,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges,756,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,806.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,771.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,604.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,483.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,907.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,2073.62,
BX TRAY,5542311E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,5542311E,CDM,360,RC,62323,HCPCS,Outpatient,,,1008,604.8,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges,756,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,806.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,771.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,604.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,705.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,483.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,907.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,2073.62,
KYPHOPLASTY THORACIC,5542513,CDM,360,RC,22513,HCPCS,Outpatient,,,13007,7804.2,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11202.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,21287.29,
KYPHOPLASTY LUMBAR,5542514,CDM,360,RC,22514,HCPCS,Outpatient,,,13007,7804.2,,21287.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6013.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,11202.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,10824.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21046.75,350,,,Fee Schedule,350% of CMS OPPS Rate,6133.62,103,,,Fee Schedule,103% of CMS OPPS Rate,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,13830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,6013.36,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,21287.29,
KYPHOPLASTY ADD LEVEL,5542515,CDM,360,RC,22515,HCPCS,Outpatient,,,13007,7804.2,,2341.26,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,2341.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9104.9,70,,,percent of total billed charges,70% of total billed charges,9755.25,75,,,percent of total billed charges,75% of total billed charges,6503.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,10405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,9950.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5853.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7804.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9104.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,13007,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,11706.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,13007,
PERC VERTEBROPLASTY THOR,5542520,CDM,360,RC,22510,HCPCS,Outpatient,,,4240,2544,,9579.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5393.36,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2968,70,,,percent of total billed charges,70% of total billed charges,3180,75,,,percent of total billed charges,75% of total billed charges,4870.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3392,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9471.28,350,,,Fee Schedule,350% of CMS OPPS Rate,2760.2,103,,,Fee Schedule,103% of CMS OPPS Rate,3243.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2544,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2968,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.98,100,,,Fee Schedule,100% of CMS OPPS Rate,2035.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3816,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,9579.52,
INSERT TUN PLEURAL CATHETER,5542551,CDM,360,RC,32550,HCPCS,Outpatient,,,3200,1920,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3200,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5579.43,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3200,103,,,Fee Schedule,103% of CMS OPPS Rate,2448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3200,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,11398.68,
INSERT TUN PLEURAL CATHETER,5542551E,CDM,360,RC,32550,HCPCS,Outpatient,,,4000,2400,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5579.43,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2800,70,,,percent of total billed charges,70% of total billed charges,3000,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3060,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2400,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1920,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3600,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,11398.68,
DRAINAGE CATH,5542551EXP,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
BAG DECANTER,5542551EXP,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5542551EXP,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
RAD GUIDANCE ABCESS DRAIN,5542551EXP,CDM,360,RC,75989,HCPCS,Outpatient,,,435.6,261.36,,78.41,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,78.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.92,70,,,percent of total billed charges,70% of total billed charges,326.7,75,,,percent of total billed charges,75% of total billed charges,217.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,348.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,435.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,392.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.41,435.6,
INSERT TUN PLEURAL CATHETER,5542551EXP,CDM,360,RC,32550,HCPCS,Outpatient,,,3200,1920,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3200,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5579.43,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3200,103,,,Fee Schedule,103% of CMS OPPS Rate,2448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3200,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,11398.68,
FIDICIAL MARKER PLACEMENT CHEST,5542553,CDM,360,RC,32553,HCPCS,Outpatient,,,1534,920.4,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1073.8,70,,,percent of total billed charges,70% of total billed charges,1150.5,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1227.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1173.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1073.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,920.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1073.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,736.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,4314.56,
PTA DRUG COATED BALLOON,5542623,CDM,272,RC,C2623,HCPCS,Outpatient,,,2204,1322.4,,396.72,18,,,percent of total billed charges,pays at 18% of total charges,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,396.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.8,70,,,percent of total billed charges,70% of total billed charges,1653,75,,,percent of total billed charges,75% of total billed charges,1102,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1763.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1322.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1686.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,379.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1542.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1322.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,837.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1542.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2204,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1983.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,345.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.37,2204,
SHOULDER ARTHROGRAM S&I LT,5543040,CDM,322,RC,73040,HCPCS,Outpatient,,,501.6,300.96,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,351.12,70,,,percent of total billed charges,70% of total billed charges,376.2,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,401.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,383.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,240.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,451.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,1185.68,
SHOULDER ARTHROGRAM S&I RT,5543040RT,CDM,322,RC,73040,HCPCS,Outpatient,,,501.6,300.96,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,351.12,70,,,percent of total billed charges,70% of total billed charges,376.2,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,401.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,383.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,300.96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,351.12,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,240.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,451.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,225.72,1185.68,
ELBOW ARTHOGRAM LT,5543085,CDM,360,RC,73085,HCPCS,Outpatient,,,365.86,219.52,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.1,70,,,percent of total billed charges,70% of total billed charges,274.4,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,164.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,175.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,329.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.03,1185.68,
ELBOW ARTHOGRAM RT,5543085RT,CDM,360,RC,73085,HCPCS,Outpatient,,,365.86,219.52,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,256.1,70,,,percent of total billed charges,70% of total billed charges,274.4,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,292.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,279.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,164.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,219.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,256.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,175.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,329.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,139.03,1185.68,
WRIST ARTHROGRAPHY LT,5543115,CDM,322,RC,73115,HCPCS,Outpatient,,,376.15,225.69,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,263.31,70,,,percent of total billed charges,70% of total billed charges,282.11,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,300.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,287.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,338.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,1185.68,
BX TRAY,5543115E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLUORO GUIDANCE,5543115E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a small joint/bursa without ultrasound,5543115E,CDM,360,RC,20600,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
WRIST ARTHROGRAPHYRT,5543115RT,CDM,322,RC,73115,HCPCS,Outpatient,,,376.15,225.69,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,263.31,70,,,percent of total billed charges,70% of total billed charges,282.11,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,300.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,287.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,263.31,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,180.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,338.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,169.27,1185.68,
SACROPLASTY BONE CEMENT,5543176,CDM,278,RC,,,Outpatient,,,318,190.8,,57.24,18,,,percent of total billed charges,pays at 18% of total charges,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.24,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,159,50,,,percent of total billed charges,pays at 50% of total billed charges,222.6,70,,,percent of total billed charges,70% of total billed charges,238.5,75,,,percent of total billed charges,75% of total billed charges,159,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,318,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,318,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.83,318,
SHOULDER ARTHROGRAM LT,5543350,CDM,360,RC,23350,HCPCS,Outpatient,,,196.68,118.01,,35.4,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,35.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,137.68,70,,,percent of total billed charges,70% of total billed charges,147.51,75,,,percent of total billed charges,75% of total billed charges,98.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.51,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,137.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,137.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,196.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,657,
SHOULDER ARTHROGRAM RT,5543350RT,CDM,360,RC,23350,HCPCS,Outpatient,,,196.68,118.01,,35.4,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,35.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,137.68,70,,,percent of total billed charges,70% of total billed charges,147.51,75,,,percent of total billed charges,75% of total billed charges,98.34,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,157.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,118.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.51,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,137.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,118.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,137.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,196.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,177.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,657,
HIP ARTHROGRAM S/I LT,5543525,CDM,322,RC,73525,HCPCS,Outpatient,,,370.26,222.16,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,259.18,70,,,percent of total billed charges,70% of total billed charges,277.7,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,296.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,283.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,166.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,333.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,166.62,1185.68,
HIP ARTHROGRAM S/I RT,5543525RT,CDM,322,RC,73525,HCPCS,Outpatient,,,370.26,222.16,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,259.18,70,,,percent of total billed charges,70% of total billed charges,277.7,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,296.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,283.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,166.62,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,259.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,177.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,333.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,166.62,1185.68,
KNEE ARTHOGRAM LT,5543580,CDM,360,RC,73580,HCPCS,Outpatient,,,526,315.6,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,368.2,70,,,percent of total billed charges,70% of total billed charges,394.5,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,402.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,236.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,199.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,473.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,199.88,1185.68,
KNEE ARTHOGRAM RT,5543580RT,CDM,360,RC,73580,HCPCS,Outpatient,,,526,315.6,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,368.2,70,,,percent of total billed charges,70% of total billed charges,394.5,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,402.39,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,236.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,199.88,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,368.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,252.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,473.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,199.88,1185.68,
ANKLE ARTHOGRAM LT,5543615,CDM,360,RC,73615,HCPCS,Outpatient,,,350.61,210.37,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.43,70,,,percent of total billed charges,70% of total billed charges,262.96,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,280.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,268.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,157.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,133.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,315.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,133.23,1185.68,
ANKLE ARTHOGRAM RT,5543615RT,CDM,360,RC,73615,HCPCS,Outpatient,,,350.61,210.37,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,930.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.43,70,,,percent of total billed charges,70% of total billed charges,262.96,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,280.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,341.63,103,,,Fee Schedule,103% of CMS OPPS Rate,268.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,157.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,133.23,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,245.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,168.29,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,315.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,133.23,1185.68,
PERCUT PLACEMENT,5543750,CDM,360,RC,43246,HCPCS,Outpatient,,,1197.2,718.32,,5604.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1197.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2735.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,838.04,70,,,percent of total billed charges,70% of total billed charges,897.9,75,,,percent of total billed charges,75% of total billed charges,2849.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,957.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5541.47,350,,,Fee Schedule,350% of CMS OPPS Rate,1197.2,103,,,Fee Schedule,103% of CMS OPPS Rate,915.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,538.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,838.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,718.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,838.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3641.53,100,,,Fee Schedule,100% of CMS OPPS Rate,574.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1197.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,538.74,5604.8,
FLUORO FOR NG TUBE,5543752,CDM,360,RC,43752,HCPCS,Outpatient,,,307,184.2,,1215.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,343.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,307,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,672.86,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,214.9,70,,,percent of total billed charges,70% of total billed charges,230.25,75,,,percent of total billed charges,75% of total billed charges,617.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,245.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1201.37,350,,,Fee Schedule,350% of CMS OPPS Rate,307,103,,,Fee Schedule,103% of CMS OPPS Rate,234.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,138.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,184.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,214.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,789.47,100,,,Fee Schedule,100% of CMS OPPS Rate,147.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,307,100,,,Fee Schedule,100% of CMS OPPS Rate,276.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,138.15,1215.1,
CHG GASTROSTOMY TUBE,5543760,CDM,360,RC,49450,HCPCS,Outpatient,,,1644,986.4,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1150.8,70,,,percent of total billed charges,70% of total billed charges,1233,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1315.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,1257.66,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,739.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1150.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,986.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1150.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,789.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1479.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,739.8,2656.66,
REPOSITION GASTRIC TUBE,5543761,CDM,360,RC,43761,HCPCS,Outpatient,,,721.58,432.95,,691.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,195.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,195.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,467.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,505.11,70,,,percent of total billed charges,70% of total billed charges,541.19,75,,,percent of total billed charges,75% of total billed charges,351.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,577.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683.68,350,,,Fee Schedule,350% of CMS OPPS Rate,199.23,103,,,Fee Schedule,103% of CMS OPPS Rate,552.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,324.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,505.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,432.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,505.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,449.27,100,,,Fee Schedule,100% of CMS OPPS Rate,346.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,649.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,100,,,Fee Schedule,100% of CMS OPPS Rate,195.33,691.48,
GASTRIC BAND ADJUSTMENT,5543999,CDM,761,RC,43999,HCPCS,Outpatient,,,1832.85,1099.71,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1374.64,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1466.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,1402.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,315.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,824.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1283,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1099.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,696.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1283,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,879.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1649.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,287.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,287.21,2656.66,
PENILE BIOPSY,5544100,CDM,360,RC,54100,HCPCS,Outpatient,,,2704.5,1622.7,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2748.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1893.15,70,,,percent of total billed charges,70% of total billed charges,2028.38,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2163.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,2068.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1893.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1622.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1893.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2434.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.03,4825.85,
ELBOW ARTHRO INJECT LT,5544221,CDM,360,RC,24220,HCPCS,Outpatient,,,184.8,110.88,,33.26,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,33.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,129.36,70,,,percent of total billed charges,70% of total billed charges,138.6,75,,,percent of total billed charges,75% of total billed charges,92.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,930.49,
ELBOW ARTHRO INJECT RT,5544221RT,CDM,360,RC,24220,HCPCS,Outpatient,,,184.8,110.88,,33.26,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,33.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,129.36,70,,,percent of total billed charges,70% of total billed charges,138.6,75,,,percent of total billed charges,75% of total billed charges,92.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,141.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,129.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,166.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,930.49,
CHOLANGRM PERC TRANSHEP,5544320,CDM,360,RC,47532,HCPCS,Outpatient,,,818.84,491.3,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,818.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,573.19,70,,,percent of total billed charges,70% of total billed charges,614.13,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,655.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,818.84,103,,,Fee Schedule,103% of CMS OPPS Rate,626.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,368.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,573.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,491.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,573.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,393.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,818.84,100,,,Fee Schedule,100% of CMS OPPS Rate,736.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,368.48,11398.68,
GI TUBE INTRODUCTION,5544340,CDM,360,RC,74340,HCPCS,Outpatient,,,384.8,230.88,,69.26,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,69.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.36,70,,,percent of total billed charges,70% of total billed charges,288.6,75,,,percent of total billed charges,75% of total billed charges,192.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,294.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,269.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,146.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,269.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,384.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,346.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.26,384.8,
GASTRO TUBE (PERC) PLACE,5544350,CDM,360,RC,49440,HCPCS,Outpatient,,,1680,1008,,5604.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2852.09,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges,1260,75,,,percent of total billed charges,75% of total billed charges,2849.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5541.47,350,,,Fee Schedule,350% of CMS OPPS Rate,1614.94,103,,,Fee Schedule,103% of CMS OPPS Rate,1285.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,756,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3641.53,100,,,Fee Schedule,100% of CMS OPPS Rate,806.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,756,5604.8,
BILIARY STENT PLACEMENT,5544363,CDM,360,RC,74363,HCPCS,Outpatient,,,947.6,568.56,,170.57,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,170.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.32,70,,,percent of total billed charges,70% of total billed charges,710.7,75,,,percent of total billed charges,75% of total billed charges,473.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,758.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,724.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,663.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,663.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,947.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,852.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.57,947.6,
COONS DILATORS,5544363E,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
GUIDEWIRES,5544363E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
ANGIO PACK,5544363E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5544363E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
BILIARY STENT TRANSHEPATIC,5544363E,CDM,278,RC,C1876,HCPCS,Outpatient,,,3201.5,1920.9,,576.27,18,,,percent of total billed charges,pays at 18% of total charges,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,576.27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2241.05,70,,,percent of total billed charges,70% of total billed charges,2401.13,75,,,percent of total billed charges,75% of total billed charges,1600.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2561.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1920.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3201.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,551.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2241.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1216.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2241.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1536.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3201.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,501.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.68,3201.5,
BILIARY STENT PLACEMENT,5544363E,CDM,360,RC,74363,HCPCS,Outpatient,,,947.6,568.56,,170.57,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,170.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.32,70,,,percent of total billed charges,70% of total billed charges,710.7,75,,,percent of total billed charges,75% of total billed charges,473.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,758.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,724.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,663.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,568.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,360.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,663.32,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.85,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,947.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,852.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.57,947.6,
INTERCOSTAL NERVE INJECTION SNGL,5544420,CDM,360,RC,64420,HCPCS,Outpatient,,,664,398.4,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,464.8,70,,,percent of total billed charges,70% of total billed charges,498,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,531.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,507.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,298.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,464.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,398.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,464.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,318.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,597.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,298.8,2073.62,
INTERCOSTAL NERVE INJECTION MULTI,5544421,CDM,360,RC,64421,HCPCS,Outpatient,,,838,502.8,,2742.49,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,774.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1370.51,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,586.6,70,,,percent of total billed charges,70% of total billed charges,628.5,75,,,percent of total billed charges,75% of total billed charges,1394.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,670.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2711.51,350,,,Fee Schedule,350% of CMS OPPS Rate,790.2,103,,,Fee Schedule,103% of CMS OPPS Rate,641.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,377.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,586.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,586.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.84,100,,,Fee Schedule,100% of CMS OPPS Rate,402.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,754.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,774.71,100,,,Fee Schedule,100% of CMS OPPS Rate,377.1,2742.49,
"UROGRAPHY, ANTEGRADE",5544425,CDM,360,RC,74425,HCPCS,Outpatient,,,266.56,159.94,,1185.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,266.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,515.31,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,186.59,70,,,percent of total billed charges,70% of total billed charges,199.92,75,,,percent of total billed charges,75% of total billed charges,602.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,213.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1172.28,350,,,Fee Schedule,350% of CMS OPPS Rate,266.56,103,,,Fee Schedule,103% of CMS OPPS Rate,203.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,119.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,186.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,159.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,101.29,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,186.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,770.36,100,,,Fee Schedule,100% of CMS OPPS Rate,127.95,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,266.56,100,,,Fee Schedule,100% of CMS OPPS Rate,239.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,334.93,100,,,Fee Schedule,100% of CMS OPPS Rate,101.29,1185.68,
SCIATIC NERVE INJECTION,5544445,CDM,360,RC,64445,HCPCS,Outpatient,,,1280,768,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,896,70,,,percent of total billed charges,70% of total billed charges,960,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1024,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,979.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,576,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,768,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,896,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,614.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1152,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,576,2073.62,
NEPH DRAIN INJ REN,5544475,CDM,360,RC,50432,HCPCS,Outpatient,,,1800,1080,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2316.41,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1260,70,,,percent of total billed charges,70% of total billed charges,1350,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1377,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,810,5969.39,
ANTEGRADE STENT URETHER I,5544480,CDM,360,RC,50433,HCPCS,Outpatient,,,1800,1080,,10314.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2913.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1800,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2316.41,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1260,70,,,percent of total billed charges,70% of total billed charges,1350,75,,,percent of total billed charges,75% of total billed charges,5244.78,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1440,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10198.2,350,,,Fee Schedule,350% of CMS OPPS Rate,1800,103,,,Fee Schedule,103% of CMS OPPS Rate,1377,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,810,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1080,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1260,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,6701.67,100,,,Fee Schedule,100% of CMS OPPS Rate,864,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1800,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.77,100,,,Fee Schedule,100% of CMS OPPS Rate,810,10314.75,
DILITATION NEPHROSTOMY,5544485,CDM,360,RC,74485,HCPCS,Outpatient,,,2000,1200,,5969.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3457.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1400,70,,,percent of total billed charges,70% of total billed charges,1500,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1600,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.94,350,,,Fee Schedule,350% of CMS OPPS Rate,1719.99,103,,,Fee Schedule,103% of CMS OPPS Rate,1530,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,900,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1200,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,760,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1400,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,960,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1800,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,760,5969.4,
LONG GASTRO TUBE IN,5544500,CDM,360,RC,44500,HCPCS,Outpatient,,,838.2,502.92,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,586.74,70,,,percent of total billed charges,70% of total billed charges,628.65,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,670.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,641.22,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,377.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,586.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,502.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,586.74,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,402.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,754.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,377.19,2656.66,
WRIST ARTHROGRAPHY INJ LT,5545246,CDM,360,RC,25246,HCPCS,Outpatient,,,220,132,,39.6,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,39.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,657,
WRIST ARTHROGRAPHY INJ RT,5545246RT,CDM,360,RC,25246,HCPCS,Outpatient,,,220,132,,39.6,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,39.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,515.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,657,
PTA VENOUS INV,5545476,CDM,360,RC,36902,HCPCS,Outpatient,,,6250,3750,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,10160.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4375,70,,,percent of total billed charges,70% of total billed charges,4687.5,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5000,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,4781.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2812.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4375,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3750,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4375,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,3000,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,5625,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2812.5,16784.25,
EXTREMITY ANGIO-UNILAT LEFT,5545710,CDM,323,RC,75710,HCPCS,Outpatient,,,2171.7,1303.02,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2171.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1520.19,70,,,percent of total billed charges,70% of total billed charges,1628.78,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1737.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2171.7,103,,,Fee Schedule,103% of CMS OPPS Rate,1661.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,977.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1520.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1303.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1520.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1042.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2171.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1954.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
EXTREMITY ANGIO-UNILAT RIGHT,5545710RT,CDM,323,RC,75710,HCPCS,Outpatient,,,2171.7,1303.02,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2171.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1520.19,70,,,percent of total billed charges,70% of total billed charges,1628.78,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1737.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2171.7,103,,,Fee Schedule,103% of CMS OPPS Rate,1661.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,977.27,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1520.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1303.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1520.19,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1042.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2171.7,100,,,Fee Schedule,100% of CMS OPPS Rate,1954.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
ANGIO PACK,5545790F,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
MICROPUNCTURE INTRODU SET,5545790F,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
BAG DECANTER,5545790F,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CREATE AV SHUNT,5545790F,CDM,360,RC,36901,HCPCS,Outpatient,,,1690,1014,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1183,70,,,percent of total billed charges,70% of total billed charges,1267.5,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1292.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,760.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1183,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1014,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1183,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,811.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1521,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,760.5,4788.21,
VENOGRAM EXTREMITY UNILAT LEFT,5545820,CDM,320,RC,75820,HCPCS,Outpatient,,,1056,633.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1056,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,739.2,70,,,percent of total billed charges,70% of total billed charges,792,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1056,103,,,Fee Schedule,103% of CMS OPPS Rate,807.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,475.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,633.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,506.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1056,100,,,Fee Schedule,100% of CMS OPPS Rate,950.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,165.48,4788.21,
VENOGRAM EXTREMITY UNILAT LEFT,5545820E,CDM,320,RC,75820,HCPCS,Outpatient,,,1056,633.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1056,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,739.2,70,,,percent of total billed charges,70% of total billed charges,792,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1056,103,,,Fee Schedule,103% of CMS OPPS Rate,807.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,475.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,633.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,506.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1056,100,,,Fee Schedule,100% of CMS OPPS Rate,950.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,165.48,4788.21,
EXTREM VENOGRAM INJ,5545820E,CDM,360,RC,36005,HCPCS,Outpatient,,,2100,1260,,378,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,378,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1606.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1890,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,2100,
VENOGRAM EXTREMITY UNILAT RIGHT,5545820RT,CDM,320,RC,75820,HCPCS,Outpatient,,,1056,633.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1056,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,739.2,70,,,percent of total billed charges,70% of total billed charges,792,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1056,103,,,Fee Schedule,103% of CMS OPPS Rate,807.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,475.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,633.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,506.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1056,100,,,Fee Schedule,100% of CMS OPPS Rate,950.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,165.48,4788.21,
VENOGRAM EXTREMITY UNILAT RIGHT,5545820RTE,CDM,320,RC,75820,HCPCS,Outpatient,,,1056,633.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1056,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,739.2,70,,,percent of total billed charges,70% of total billed charges,792,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,844.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1056,103,,,Fee Schedule,103% of CMS OPPS Rate,807.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,475.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,633.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,739.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,506.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1056,100,,,Fee Schedule,100% of CMS OPPS Rate,950.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,165.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,165.48,4788.21,
EXTREM VENOGRAM INJ,5545820RTE,CDM,360,RC,36005,HCPCS,Outpatient,,,2100,1260,,378,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,378,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1606.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1890,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,2100,
VENOGRAM EXT BILAT S/I,5545822,CDM,320,RC,75822,HCPCS,Outpatient,,,1152,691.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1152,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,806.4,70,,,percent of total billed charges,70% of total billed charges,864,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,921.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1152,103,,,Fee Schedule,103% of CMS OPPS Rate,881.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,518.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,806.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,691.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,806.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,552.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1152,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,180.52,4788.21,
VENOGRAM EXT BILAT S/I,5545822E,CDM,320,RC,75822,HCPCS,Outpatient,,,1152,691.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1152,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,806.4,70,,,percent of total billed charges,70% of total billed charges,864,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,921.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1152,103,,,Fee Schedule,103% of CMS OPPS Rate,881.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,198.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,518.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,806.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,691.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,806.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,552.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1152,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,180.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,180.52,4788.21,
EXTREM VENOGRAM INJ,5545822E,CDM,360,RC,36005,HCPCS,Outpatient,,,2100,1260,,378,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,378,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1606.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1890,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,2100,
IVC VENOGRAPHY S/I,5545825,CDM,320,RC,75825,HCPCS,Outpatient,,,2772.83,1663.7,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1940.98,70,,,percent of total billed charges,70% of total billed charges,2079.62,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2218.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,2121.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,477.76,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.77,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1940.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1663.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1940.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2495.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,434.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.96,
SVC VENOGRAPHY S/I,5545827,CDM,320,RC,75827,HCPCS,Outpatient,,,1773.72,1064.23,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1241.6,70,,,percent of total billed charges,70% of total billed charges,1330.29,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1418.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1356.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,305.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,798.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1241.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1064.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1241.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,851.39,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1596.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,277.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,277.94,4788.21,
HEPATIC VENOGRAPHY,554-5891,CDM,360,RC,75891,HCPCS,Outpatient,,,5584,3350.4,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,3908.8,70,,,percent of total billed charges,70% of total billed charges,4188,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4467.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,4271.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2512.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3908.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3350.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2121.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3908.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2680.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5025.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2121.92,9586.96,
EXISTING CATH ANGIOGR FU,5545898,CDM,323,RC,75898,HCPCS,Outpatient,,,1600.56,960.34,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1600.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1120.39,70,,,percent of total billed charges,70% of total billed charges,1200.42,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,1600.56,103,,,Fee Schedule,103% of CMS OPPS Rate,1224.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,720.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960.34,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,1120.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,768.27,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1600.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1440.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,364,9586.95,
FIBRIN STRAPPING,5545901,CDM,360,RC,75901,HCPCS,Outpatient,,,450.9,270.54,,81.16,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,81.16,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.63,70,,,percent of total billed charges,70% of total billed charges,338.18,75,,,percent of total billed charges,75% of total billed charges,225.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,360.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,270.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,344.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,315.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,270.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,315.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.43,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,450.9,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,405.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.16,450.9,
MECH INTRALUM REMVL OBAT,5545902,CDM,360,RC,75902,HCPCS,Outpatient,,,354.6,212.76,,63.83,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,63.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.22,70,,,percent of total billed charges,70% of total billed charges,265.95,75,,,percent of total billed charges,75% of total billed charges,177.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,283.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,271.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,248.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,248.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,354.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,319.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.83,354.6,
DILATION OF RECTAL STRICTURE,5545910,CDM,360,RC,45910,HCPCS,Outpatient,,,4767,2860.2,,3485.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,984.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,984.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1909.21,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3336.9,70,,,percent of total billed charges,70% of total billed charges,3575.25,75,,,percent of total billed charges,75% of total billed charges,1772.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3813.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3445.65,350,,,Fee Schedule,350% of CMS OPPS Rate,1004.15,103,,,Fee Schedule,103% of CMS OPPS Rate,3646.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2145.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3336.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2860.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3336.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2264.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2288.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,4290.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,4290.3,
PERC PLCMNT IVC FILTER,5545940,CDM,360,RC,37191,HCPCS,Outpatient,,,2226.84,1336.1,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2226.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1558.79,70,,,percent of total billed charges,70% of total billed charges,1670.13,75,,,percent of total billed charges,75% of total billed charges,8410.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1781.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,2226.84,103,,,Fee Schedule,103% of CMS OPPS Rate,1703.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1558.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1336.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1558.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2226.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2004.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.08,16540.84,
TC RETRIEVAL OF IV FB,5545961,CDM,360,RC,37197,HCPCS,Outpatient,,,3933.72,2360.23,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2753.6,70,,,percent of total billed charges,70% of total billed charges,2950.29,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3146.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,3009.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1770.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2753.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2360.23,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2753.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1888.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3540.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1770.17,9586.95,
TRANSCATHETER BIOPSY S & I,5545970,CDM,360,RC,75970,HCPCS,Outpatient,,,1545.6,927.36,,278.21,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,278.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.92,70,,,percent of total billed charges,70% of total billed charges,1159.2,75,,,percent of total billed charges,75% of total billed charges,772.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1236.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,927.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1182.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1081.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,927.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,587.33,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1081.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1545.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1391.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.21,1545.6,
PTH BILI DRAIN WCONTR MON,5545980,CDM,360,RC,47533,HCPCS,Outpatient,,,1004,602.4,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1004,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,702.8,70,,,percent of total billed charges,70% of total billed charges,753,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,803.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,1004,103,,,Fee Schedule,103% of CMS OPPS Rate,768.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,451.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,702.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,602.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,702.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,481.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1004,100,,,Fee Schedule,100% of CMS OPPS Rate,903.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,451.8,11398.68,
INT/EXT DRAIN S/I,5545982,CDM,360,RC,47534,HCPCS,Outpatient,,,952.56,571.54,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,952.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3976.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,666.79,70,,,percent of total billed charges,70% of total billed charges,714.42,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,762.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,952.56,103,,,Fee Schedule,103% of CMS OPPS Rate,728.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,428.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,666.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,571.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,666.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,457.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,952.56,100,,,Fee Schedule,100% of CMS OPPS Rate,857.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,428.65,11398.68,
CHG DRAINAGE CATH,5545984,CDM,360,RC,75984,HCPCS,Outpatient,,,319,191.4,,57.42,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,57.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.3,70,,,percent of total billed charges,70% of total billed charges,239.25,75,,,percent of total billed charges,75% of total billed charges,159.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,255.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,191.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,244.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,223.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,121.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,223.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,319,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,287.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.42,319,
RAD GUIDANCE ABCESS DRAIN,5545989,CDM,360,RC,75989,HCPCS,Outpatient,,,435.6,261.36,,78.41,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,78.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.92,70,,,percent of total billed charges,70% of total billed charges,326.7,75,,,percent of total billed charges,75% of total billed charges,217.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,348.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,435.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,392.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.41,435.6,
FLUORO GUID CENT VEN ACCE,5545998,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",5546000,CDM,320,RC,76000,HCPCS,Outpatient,,,833.76,500.26,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,583.63,70,,,percent of total billed charges,70% of total billed charges,625.32,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,667.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,637.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,143.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,375.19,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,500.26,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,583.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.26,100,,,Fee Schedule,100% of CMS OPPS Rate,400.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,750.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,130.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,130.65,751.51,
THYROID CYST ASP/INJ,5546001,CDM,360,RC,60300,HCPCS,Outpatient,,,1173,703.8,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,821.1,70,,,percent of total billed charges,70% of total billed charges,879.75,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,897.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,527.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,821.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,703.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,821.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,563.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,527.85,2088.52,
BX TRAY,5546001E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
US GUIDED NDLE PLACEMENT,5546001E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
THYROID CYST ASP/INJ,5546001E,CDM,360,RC,60300,HCPCS,Outpatient,,,1173,703.8,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,821.1,70,,,percent of total billed charges,70% of total billed charges,879.75,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,938.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,897.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,527.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,821.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,703.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,821.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,563.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,527.85,2088.52,
FLUORO GUIDANCE,5546003,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
EXTREM VENOGRAM INJ,5546005,CDM,360,RC,36005,HCPCS,Outpatient,,,2100,1260,,378,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,378,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,1050,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1606.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1890,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378,2100,
FLUORO NDL LOC SPINAL INJ,5546006,CDM,360,RC,77003,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,221.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.76,582.01,
SUP/INFER VENA CAVA,5546010,CDM,360,RC,36010,HCPCS,Outpatient,,,755,453,,135.9,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,135.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,528.5,70,,,percent of total billed charges,70% of total billed charges,566.25,75,,,percent of total billed charges,75% of total billed charges,377.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,604,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,453,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,577.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,528.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,453,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,528.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,755,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,679.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.9,5082.45,
FISTULA/SINUS TRACT STY,5546080,CDM,360,RC,76080,HCPCS,Outpatient,,,355.76,213.46,,1619.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,457.39,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,355.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.03,70,,,percent of total billed charges,70% of total billed charges,266.82,75,,,percent of total billed charges,75% of total billed charges,823.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,284.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600.88,350,,,Fee Schedule,350% of CMS OPPS Rate,355.76,103,,,Fee Schedule,103% of CMS OPPS Rate,272.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,160.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,135.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,1052,100,,,Fee Schedule,100% of CMS OPPS Rate,170.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,355.76,100,,,Fee Schedule,100% of CMS OPPS Rate,320.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,457.39,100,,,Fee Schedule,100% of CMS OPPS Rate,135.19,1619.18,
CREATE AV SHUNT,5546145,CDM,360,RC,36901,HCPCS,Outpatient,,,1690,1014,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1183,70,,,percent of total billed charges,70% of total billed charges,1267.5,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1292.85,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,760.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1183,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1014,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1183,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,811.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1521,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,760.5,4788.21,
ADDITIONAL  AV DIAL SHUNT ACCESS,554-6148,CDM,320,RC,36148,HCPCS,Outpatient,,,598,358.8,,107.64,18,,,percent of total billed charges,pays at 18% of total charges,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,299,50,,,percent of total billed charges,pays at 50% of total billed charges,418.6,70,,,percent of total billed charges,70% of total billed charges,448.5,75,,,percent of total billed charges,75% of total billed charges,299,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,478.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,457.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,418.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,358.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,418.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,598,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,538.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,93.71,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.71,598,
ANGIO SELECT RENAL UNILAT,5546251,CDM,761,RC,36251,HCPCS,Outpatient,,,6478,3886.8,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,4858.5,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,4955.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1116.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2915.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4534.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3886.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2461.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4534.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5830.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.1,9586.96,
ANGIO SELECT RENAL BILAT,5546252,CDM,761,RC,36252,HCPCS,Outpatient,,,6478,3886.8,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,4858.5,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,4955.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1116.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2915.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4534.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3886.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2461.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4534.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5830.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.1,9586.96,
ANGIO SECOND ORDER RENAL UNI,5546253,CDM,761,RC,36253,HCPCS,Outpatient,,,10797.5,6478.5,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,8098.13,75,,,percent of total billed charges,75% of total billed charges,8410.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8638,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4766,103,,,Fee Schedule,103% of CMS OPPS Rate,8260.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1860.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4858.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7558.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6478.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4103.05,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,7558.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,5182.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,9717.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1691.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1691.97,16540.84,
ANGIO SECOND ORDER RENAL,5546254,CDM,761,RC,36254,HCPCS,Outpatient,,,6478,3886.8,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,4858.5,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5182.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,4955.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1116.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2915.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4534.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3886.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2461.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4534.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,3109.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,5830.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1015.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.1,9586.96,
BLOOD PATCH-EPIDURAL,5546273,CDM,360,RC,62273,HCPCS,Outpatient,,,710,426,,2073.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.77,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,497,70,,,percent of total billed charges,70% of total billed charges,532.5,75,,,percent of total billed charges,75% of total billed charges,1054.38,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,568,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2050.19,350,,,Fee Schedule,350% of CMS OPPS Rate,597.47,103,,,Fee Schedule,103% of CMS OPPS Rate,543.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,319.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,497,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,426,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,497,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.26,100,,,Fee Schedule,100% of CMS OPPS Rate,340.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,639,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,585.77,100,,,Fee Schedule,100% of CMS OPPS Rate,319.5,2073.62,
PORTAL VEIN CATH,5546481,CDM,360,RC,36481,HCPCS,Outpatient,,,2800,1680,,504,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,504,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960,70,,,percent of total billed charges,70% of total billed charges,2100,75,,,percent of total billed charges,75% of total billed charges,1400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2142,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,2520,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504,2800,
VENOUS CATH,5546500,CDM,360,RC,36500,HCPCS,Outpatient,,,800,480,,144,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,144,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,560,70,,,percent of total billed charges,70% of total billed charges,600,75,,,percent of total billed charges,75% of total billed charges,400,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,640,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,612,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,480,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,560,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,384,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,800,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,720,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,8695.83,
REV. IMPL. VENOUS ACCESS,5546534,CDM,360,RC,36575,HCPCS,Outpatient,,,1293.6,776.16,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,905.52,70,,,percent of total billed charges,70% of total billed charges,970.2,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1034.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,989.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,582.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,905.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,776.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,905.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,620.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
REM IMPLANTABLE PORT,5546535,CDM,360,RC,36589,HCPCS,Outpatient,,,1200,720,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges,900,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,960,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.43,103,,,Fee Schedule,103% of CMS OPPS Rate,918,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,540,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,720,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,840,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,100,,,Fee Schedule,100% of CMS OPPS Rate,576,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1080,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
DECLOT IMP VAD/CATH THROM,5546550,CDM,360,RC,36593,HCPCS,Outpatient,,,305.36,183.22,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,213.75,70,,,percent of total billed charges,70% of total billed charges,229.02,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,244.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,305.36,103,,,Fee Schedule,103% of CMS OPPS Rate,233.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,137.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,213.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,213.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,146.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,274.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,137.41,1070.43,
PEDI CENTRAL LINE,5546555,CDM,360,RC,36555,HCPCS,Outpatient,,,1130.4,678.24,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1130.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,791.28,70,,,percent of total billed charges,70% of total billed charges,847.8,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,904.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,1130.4,103,,,Fee Schedule,103% of CMS OPPS Rate,864.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,508.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,791.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,791.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,542.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1130.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1017.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,508.68,9586.95,
ANGIO PACK,5546555E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
MICROPUNCTURE INTRODU SET,5546555E,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
BAG DECANTER,5546555E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
US GUIDE VASCULAR ACCESS,5546555E,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546555E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
PEDI CENTRAL LINE,5546555E,CDM,360,RC,36555,HCPCS,Outpatient,,,1130.4,678.24,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1130.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,791.28,70,,,percent of total billed charges,70% of total billed charges,847.8,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,904.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,1130.4,103,,,Fee Schedule,103% of CMS OPPS Rate,864.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,508.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,791.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,678.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,791.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,542.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1130.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1017.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,508.68,9586.95,
TRIPLE LUMEN CATH,5546555E,CDM,272,RC,C1751,HCPCS,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
INS NONTUN CV CATH 5YRS>,5546556,CDM,360,RC,36556,HCPCS,Outpatient,,,2104,1262.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2104,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges,1578,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2104,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2104,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,9586.95,
ANGIO PACK,5546556C,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
MICROPUNCTURE INTRODU SET,5546556C,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
BAG DECANTER,5546556C,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
US GUIDE VASCULAR ACCESS,5546556C,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546556C,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
TRIPLE LUMEN CATH,5546556C,CDM,272,RC,C1751,HCPCS,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
INS NONTUN CV CATH 5YRS>,5546556C,CDM,360,RC,36556,HCPCS,Outpatient,,,2104,1262.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2104,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges,1578,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2104,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2104,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,9586.95,
ANGIO PACK,5546556M,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
MICROPUNCTURE INTRODU SET,5546556M,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
BAG DECANTER,5546556M,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CATH HEMO DYAL SHORT TERM,5546556M,CDM,278,RC,C1752,HCPCS,Outpatient,,,223.5,134.1,,40.23,18,,,percent of total billed charges,pays at 18% of total charges,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.45,70,,,percent of total billed charges,70% of total billed charges,167.63,75,,,percent of total billed charges,75% of total billed charges,111.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.02,223.5,
US GUIDE VASCULAR ACCESS,5546556M,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546556M,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
INS NONTUN CV CATH 5YRS>,5546556M,CDM,360,RC,36556,HCPCS,Outpatient,,,2104,1262.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2104,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges,1578,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2104,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2104,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,9586.95,
INS NONTUN CV CATH 5YRS> RIGHT,5546556RT,CDM,360,RC,36556,HCPCS,Outpatient,,,2104,1262.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2104,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges,1578,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2104,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2104,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,9586.95,
ANGIO PACK,5546556RTC,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
MICROPUNCTURE INTRODU SET,5546556RTC,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
BAG DECANTER,5546556RTC,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
US GUIDE VASCULAR ACCESS,5546556RTC,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546556RTC,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
TRIPLE LUMEN CATH,5546556RTC,CDM,272,RC,C1751,HCPCS,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
INS NONTUN CV CATH 5YRS> RIGHT,5546556RTC,CDM,360,RC,36556,HCPCS,Outpatient,,,2104,1262.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2104,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges,1578,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2104,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2104,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,9586.95,
MICROPUNCTURE INTRODU SET,5546556RTM,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
ANGIO PACK,5546556RTM,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5546556RTM,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CATH HEMO DYAL SHORT TERM,5546556RTM,CDM,278,RC,C1752,HCPCS,Outpatient,,,223.5,134.1,,40.23,18,,,percent of total billed charges,pays at 18% of total charges,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.45,70,,,percent of total billed charges,70% of total billed charges,167.63,75,,,percent of total billed charges,75% of total billed charges,111.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.02,223.5,
US GUIDE VASCULAR ACCESS,5546556RTM,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546556RTM,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
INS NONTUN CV CATH 5YRS> RIGHT,5546556RTM,CDM,360,RC,36556,HCPCS,Outpatient,,,2104,1262.4,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2104,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges,1578,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1683.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2104,103,,,Fee Schedule,103% of CMS OPPS Rate,1609.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,946.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1262.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1472.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2104,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,915,9586.95,
TUNNEL CATH W/O PORT,5546558,CDM,360,RC,36558,HCPCS,Outpatient,,,2940,1764,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2058,70,,,percent of total billed charges,70% of total billed charges,2205,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2249.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1323,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2058,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1764,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2058,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1411.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2646,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1323,9586.95,
BAG DECANTER,5546558E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CATH HEMODIALY LONG TERM,5546558E,CDM,278,RC,C1750,HCPCS,Outpatient,,,662.5,397.5,,119.25,18,,,percent of total billed charges,pays at 18% of total charges,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.75,70,,,percent of total billed charges,70% of total billed charges,496.88,75,,,percent of total billed charges,75% of total billed charges,331.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,530,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.81,662.5,
ANGIO PACK,5546558E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
FLUORO GUID CENT VEN ACCE,5546558E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
TUNNEL CATH W/O PORT,5546558E,CDM,360,RC,36558,HCPCS,Outpatient,,,2940,1764,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2058,70,,,percent of total billed charges,70% of total billed charges,2205,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2352,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2249.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1323,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2058,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1764,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2058,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1411.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2646,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1323,9586.95,
INS TUN CVAD W PORT 5YRS>,5546561,CDM,360,RC,36561,HCPCS,Outpatient,,,3600,2160,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2520,70,,,percent of total billed charges,70% of total billed charges,2700,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2754,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1728,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3240,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,9586.95,
COONS DILATORS,5546561E,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
ANGIO PACK,5546561E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5546561E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
MICROPUNCTURE INTRODU SET,5546561E,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
MICROPORT,5546561E,CDM,278,RC,C1788,HCPCS,Outpatient,,,1167.65,700.59,,210.18,18,,,percent of total billed charges,pays at 18% of total charges,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.36,70,,,percent of total billed charges,70% of total billed charges,875.74,75,,,percent of total billed charges,75% of total billed charges,583.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,934.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,700.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1167.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,201.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,817.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,700.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,817.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1167.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1167.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.97,1167.65,
FLUORO GUID CENT VEN ACCE,5546561E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
US GUIDE VASCULAR ACCESS,5546561E,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
INS TUN CVAD W PORT 5YRS>,5546561E,CDM,360,RC,36561,HCPCS,Outpatient,,,3600,2160,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2520,70,,,percent of total billed charges,70% of total billed charges,2700,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2754,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1728,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3240,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,9586.95,
PEDI PICC,5546568,CDM,360,RC,36568,HCPCS,Outpatient,,,1187,712.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1187,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,830.9,70,,,percent of total billed charges,70% of total billed charges,890.25,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,949.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1187,103,,,Fee Schedule,103% of CMS OPPS Rate,908.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,534.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,830.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,830.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,569.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1187,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,534.15,4788.21,
DUAL LUMEN PICC LINE,5546568E,CDM,272,RC,,,Outpatient,,,248,148.8,,44.64,18,,,percent of total billed charges,pays at 18% of total charges,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124,50,,,percent of total billed charges,pays at 50% of total billed charges,173.6,70,,,percent of total billed charges,70% of total billed charges,186,75,,,percent of total billed charges,75% of total billed charges,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,248,
ANGIO PACK,5546568E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5546568E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
US GUIDE VASCULAR ACCESS,5546568E,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546568E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
PEDI PICC,5546568E,CDM,360,RC,36568,HCPCS,Outpatient,,,1187,712.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1187,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,830.9,70,,,percent of total billed charges,70% of total billed charges,890.25,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,949.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1187,103,,,Fee Schedule,103% of CMS OPPS Rate,908.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,534.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,830.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,712.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,830.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,569.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1187,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,534.15,4788.21,
PICC INSERTION,5546568E,CDM,360,RC,36569,HCPCS,Outpatient,,,2086,1251.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1460.2,70,,,percent of total billed charges,70% of total billed charges,1564.5,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1595.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,938.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1460.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1251.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1460.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1877.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
PICC INSERTION,5546569,CDM,360,RC,36569,HCPCS,Outpatient,,,2086,1251.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1460.2,70,,,percent of total billed charges,70% of total billed charges,1564.5,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1595.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,938.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1460.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1251.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1460.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1877.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
DUAL LUMEN PICC LINE,5546569E,CDM,272,RC,,,Outpatient,,,248,148.8,,44.64,18,,,percent of total billed charges,pays at 18% of total charges,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124,50,,,percent of total billed charges,pays at 50% of total billed charges,173.6,70,,,percent of total billed charges,70% of total billed charges,186,75,,,percent of total billed charges,75% of total billed charges,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,248,
BAG DECANTER,5546569E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5546569E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
US GUIDE VASCULAR ACCESS,5546569E,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
FLUORO GUID CENT VEN ACCE,5546569E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
PICC INSERTION,5546569E,CDM,360,RC,36569,HCPCS,Outpatient,,,2086,1251.6,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1460.2,70,,,percent of total billed charges,70% of total billed charges,1564.5,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1668.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1595.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,938.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1460.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1251.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1460.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1877.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4788.21,
INS PICC DEV W PORT 5YRS>,5546571,CDM,360,RC,36571,HCPCS,Outpatient,,,2800,1680,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1960,70,,,percent of total billed charges,70% of total billed charges,2100,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2240,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2142,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1260,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1680,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1960,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1344,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2520,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1260,9586.95,
REPAIR CVA CATHETER,5546575,CDM,360,RC,36575,HCPCS,Outpatient,,,1293.6,776.16,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,905.52,70,,,percent of total billed charges,70% of total billed charges,970.2,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1034.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,989.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,582.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,905.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,776.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,905.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,620.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
CATHETER REPAIR KIT,5546575E,CDM,272,RC,,,Outpatient,,,400,240,,72,18,,,percent of total billed charges,pays at 18% of total charges,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200,50,,,percent of total billed charges,pays at 50% of total billed charges,280,70,,,percent of total billed charges,70% of total billed charges,300,75,,,percent of total billed charges,75% of total billed charges,200,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,320,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,306,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,152,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,280,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,400,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,360,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.68,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.68,400,
REPAIR CVA CATHETER,5546575E,CDM,360,RC,36575,HCPCS,Outpatient,,,1293.6,776.16,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,905.52,70,,,percent of total billed charges,70% of total billed charges,970.2,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1034.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.42,103,,,Fee Schedule,103% of CMS OPPS Rate,989.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,582.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,905.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,776.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,905.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.59,100,,,Fee Schedule,100% of CMS OPPS Rate,620.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
REPAIR PORT,5546576,CDM,360,RC,36576,HCPCS,Outpatient,,,1124.8,674.88,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1124.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,787.36,70,,,percent of total billed charges,70% of total billed charges,843.6,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,899.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1124.8,103,,,Fee Schedule,103% of CMS OPPS Rate,860.47,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,506.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,787.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,674.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,787.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,539.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1124.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1012.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,506.16,4788.21,
TUNNEL CATH W/PORT PARTIA,5546578,CDM,360,RC,36578,HCPCS,Outpatient,,,2828,1696.8,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1979.6,70,,,percent of total billed charges,70% of total billed charges,2121,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2163.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1696.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2545.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,9586.95,
PERIPH CATH W/PORT PARTIA,5546579,CDM,360,RC,36578,HCPCS,Outpatient,,,2828,1696.8,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1979.6,70,,,percent of total billed charges,70% of total billed charges,2121,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2163.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1696.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2545.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,9586.95,
NON-TUNNEL CATH REPLACE,5546580,CDM,360,RC,36580,HCPCS,Outpatient,,,1512,907.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges,1134,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1156.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,907.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,725.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,4788.21,
BAG DECANTER,5546580E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5546580E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
CATH HEMO DYAL SHORT TERM,5546580E,CDM,278,RC,C1752,HCPCS,Outpatient,,,223.5,134.1,,40.23,18,,,percent of total billed charges,pays at 18% of total charges,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.23,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.45,70,,,percent of total billed charges,70% of total billed charges,167.63,75,,,percent of total billed charges,75% of total billed charges,111.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,223.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,84.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.45,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.02,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.02,223.5,
FLUORO GUID CENT VEN ACCE,5546580E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
NON-TUNNEL CATH REPLACE,5546580E,CDM,360,RC,36580,HCPCS,Outpatient,,,1512,907.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges,1134,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1156.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,907.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,725.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,4788.21,
REPLACE TUNNELED CV CATH,5546581,CDM,360,RC,36581,HCPCS,Outpatient,,,3360,2016,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2352,70,,,percent of total billed charges,70% of total billed charges,2520,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2688,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2570.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2352,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2016,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2352,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1612.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3024,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,9586.95,
GUIDEWIRES,5546581E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
ANGIO PACK,5546581E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5546581E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
CATH HEMODIALY LONG TERM,5546581E,CDM,278,RC,C1750,HCPCS,Outpatient,,,662.5,397.5,,119.25,18,,,percent of total billed charges,pays at 18% of total charges,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.25,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.75,70,,,percent of total billed charges,70% of total billed charges,496.88,75,,,percent of total billed charges,75% of total billed charges,331.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,530,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,662.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,114.15,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,397.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,662.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.81,662.5,
FLUORO GUID CENT VEN ACCE,5546581E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
REPLACE TUNNELED CV CATH,5546581E,CDM,360,RC,36581,HCPCS,Outpatient,,,3360,2016,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2352,70,,,percent of total billed charges,70% of total billed charges,2520,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2688,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2570.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2352,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2016,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2352,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1612.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3024,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,9586.95,
REPL TUNNELED VAD W PORT,5546582,CDM,360,RC,36582,HCPCS,Outpatient,,,3600,2160,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2520,70,,,percent of total billed charges,70% of total billed charges,2700,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2880,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2754,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2160,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2520,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1728,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3240,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1620,9586.95,
REPLACE PICC CATH,5546584,CDM,360,RC,36584,HCPCS,Outpatient,,,1588,952.8,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1111.6,70,,,percent of total billed charges,70% of total billed charges,1191,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1214.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,714.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1111.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,952.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1111.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,762.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1429.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,714.6,4788.21,
DUAL LUMEN PICC LINE,5546584E,CDM,272,RC,,,Outpatient,,,248,148.8,,44.64,18,,,percent of total billed charges,pays at 18% of total charges,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124,50,,,percent of total billed charges,pays at 50% of total billed charges,173.6,70,,,percent of total billed charges,70% of total billed charges,186,75,,,percent of total billed charges,75% of total billed charges,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,248,
ANGIO PACK,5546584E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5546584E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
FLUORO GUID CENT VEN ACCE,5546584E,CDM,320,RC,77001,HCPCS,Outpatient,,,1029.2,617.52,,185.26,18,,,percent of total billed charges,pays at 18% of total charges,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,185.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.44,70,,,percent of total billed charges,70% of total billed charges,771.9,75,,,percent of total billed charges,75% of total billed charges,514.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,823.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,787.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,177.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,617.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,720.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1029.2,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,926.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.28,1029.2,
REPLACE PICC CATH,5546584E,CDM,360,RC,36584,HCPCS,Outpatient,,,1588,952.8,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1111.6,70,,,percent of total billed charges,70% of total billed charges,1191,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1270.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1214.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,714.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1111.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,952.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1111.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,762.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1429.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,714.6,4788.21,
REPL PERIPH VAD W PORT,5546585,CDM,360,RC,36585,HCPCS,Outpatient,,,2828,1696.8,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1979.6,70,,,percent of total billed charges,70% of total billed charges,2121,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2262.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2163.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1696.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1979.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2545.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.6,9586.95,
REMOVE TNL CV CATH,5546589,CDM,360,RC,36589,HCPCS,Outpatient,,,1260,756,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges,945,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.43,103,,,Fee Schedule,103% of CMS OPPS Rate,963.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,567,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,100,,,Fee Schedule,100% of CMS OPPS Rate,604.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
ANGIO PACK,5546589C,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
REMOVE TNL CV CATH,5546589C,CDM,360,RC,36589,HCPCS,Outpatient,,,1260,756,,1861.73,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,525.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges,945,75,,,percent of total billed charges,75% of total billed charges,946.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1008,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1840.7,350,,,Fee Schedule,350% of CMS OPPS Rate,536.43,103,,,Fee Schedule,103% of CMS OPPS Rate,963.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,567,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,756,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,882,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,100,,,Fee Schedule,100% of CMS OPPS Rate,604.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,1861.73,
REM TUN CVAD W PORT/PUMP,5546590,CDM,360,RC,36590,HCPCS,Outpatient,,,1680,1008,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges,1260,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1285.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,756,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,806.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,756,4788.21,
BAG DECANTER,5546590E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5546590E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
REM TUN CVAD W PORT/PUMP,5546590E,CDM,360,RC,36590,HCPCS,Outpatient,,,1680,1008,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1248.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges,1260,75,,,percent of total billed charges,75% of total billed charges,2434.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.11,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1285.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,756,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.99,100,,,Fee Schedule,100% of CMS OPPS Rate,806.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,756,4788.21,
MECH REN INTRALUM OBST,5546596,CDM,360,RC,36596,HCPCS,Outpatient,,,1512,907.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges,1134,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1156.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,907.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,725.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,4788.21,
GLIDEWIRES,5546596E,CDM,272,RC,C1769,HCPCS,Outpatient,,,169,101.4,,30.42,18,,,percent of total billed charges,pays at 18% of total charges,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,75,,,percent of total billed charges,75% of total billed charges,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
GLIDECATHS,5546596E,CDM,272,RC,,,Outpatient,,,184,110.4,,33.12,18,,,percent of total billed charges,pays at 18% of total charges,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,184,
ANGIO PACK,5546596E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5546596E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
MECH INTRALUM REMVL OBAT,5546596E,CDM,360,RC,75902,HCPCS,Outpatient,,,354.6,212.76,,63.83,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,63.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.22,70,,,percent of total billed charges,70% of total billed charges,265.95,75,,,percent of total billed charges,75% of total billed charges,177.3,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,283.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,212.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,271.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,248.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,134.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,248.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,354.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,319.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.83,354.6,
MECH REN INTRALUM OBST,5546596E,CDM,360,RC,36596,HCPCS,Outpatient,,,1512,907.2,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges,1134,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1209.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1156.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,907.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1058.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,725.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,680.4,4788.21,
REPOSIT CVC W FLUORO,5546597,CDM,360,RC,36597,HCPCS,Outpatient,,,1680,1008,,4788.21,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1352.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2004.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges,1260,75,,,percent of total billed charges,75% of total billed charges,2434.67,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1344,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4734.1,350,,,Fee Schedule,350% of CMS OPPS Rate,1379.65,103,,,Fee Schedule,103% of CMS OPPS Rate,1285.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,756,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1008,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1176,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,3110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,806.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.6,100,,,Fee Schedule,100% of CMS OPPS Rate,756,4788.21,
BIOPSY TRAY,5546826,CDM,272,RC,,,Outpatient,,,88,52.8,,15.84,18,,,percent of total billed charges,pays at 18% of total charges,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44,50,,,percent of total billed charges,pays at 50% of total billed charges,61.6,70,,,percent of total billed charges,70% of total billed charges,66,75,,,percent of total billed charges,75% of total billed charges,44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,33.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,61.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.79,88,
BIOPSY NEEDLES,5546827,CDM,272,RC,,,Outpatient,,,161.5,96.9,,29.07,18,,,percent of total billed charges,pays at 18% of total charges,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,80.75,50,,,percent of total billed charges,pays at 50% of total billed charges,113.05,70,,,percent of total billed charges,70% of total billed charges,121.13,75,,,percent of total billed charges,75% of total billed charges,80.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,129.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,113.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,145.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.31,161.5,
BAG DECANTER,5546828,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
PERC THROMBECT GRAFT,5546870,CDM,360,RC,36905,HCPCS,Outpatient,,,10789,6473.4,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21429.78,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,7552.3,70,,,percent of total billed charges,70% of total billed charges,8091.75,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,8631.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,8253.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,4855.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7552.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6473.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,7552.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5178.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9710.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
FISTULAGRAM BALLON /STENT,5546903,CDM,360,RC,36903,HCPCS,Outpatient,,,14000,8400,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21429.78,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,9800,70,,,percent of total billed charges,70% of total billed charges,10500,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,11200,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,10710,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6300,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,9800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,8400,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,9800,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,6720,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12600,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
DECLOT BALLOON /STENT,5546906,CDM,360,RC,36906,HCPCS,Outpatient,,,32369,19421.4,,55281.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15616.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32663.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,22658.3,70,,,percent of total billed charges,70% of total billed charges,24276.75,75,,,percent of total billed charges,75% of total billed charges,28109.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,25895.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,54656.53,350,,,Fee Schedule,350% of CMS OPPS Rate,15928.47,103,,,Fee Schedule,103% of CMS OPPS Rate,24762.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,14566.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,22658.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,19421.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,22658.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,35917.15,100,,,Fee Schedule,100% of CMS OPPS Rate,15537.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,29132.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,15616.14,100,,,Fee Schedule,100% of CMS OPPS Rate,4185,55281.18,
CENTRAL BALLOON ANGIOPLASTY,5546907,CDM,360,RC,36907,HCPCS,Outpatient,,,1744,1046.4,,313.92,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,313.92,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1220.8,70,,,percent of total billed charges,70% of total billed charges,1308,75,,,percent of total billed charges,75% of total billed charges,872,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1395.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1046.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1334.16,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1046.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1220.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,837.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1744,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1569.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.92,1744,
CENTRAL BALLOON /STENT,5546908,CDM,360,RC,36908,HCPCS,Outpatient,,,6180,3708,,1112.4,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,1112.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4326,70,,,percent of total billed charges,70% of total billed charges,4635,75,,,percent of total billed charges,75% of total billed charges,3090,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4944,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3708,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4727.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2781,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4326,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3708,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4326,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2966.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6180,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5562,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657,6180,
US GUIDE VASCULAR ACCESS,5546937,CDM,402,RC,76937,HCPCS,Outpatient,,,405.36,243.22,,72.96,18,,,percent of total billed charges,pays at 18% of total charges,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.96,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.75,70,,,percent of total billed charges,70% of total billed charges,304.02,75,,,percent of total billed charges,75% of total billed charges,202.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,324.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,310.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.41,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,243.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,283.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,405.36,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,364.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.52,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.52,446,
US GUIDED RF ABLATION,5546940,CDM,402,RC,76940,HCPCS,Outpatient,,,200,120,,36,18,,,percent of total billed charges,pays at 18% of total charges,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,70,,,percent of total billed charges,70% of total billed charges,150,75,,,percent of total billed charges,75% of total billed charges,100,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,160,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,34.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,120,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,140,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,200,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,180,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.34,446,
US GUIDED NDLE PLACEMENT,5546942,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
LIVER BIOPSY,5547000,CDM,360,RC,47000,HCPCS,Outpatient,,,1582,949.2,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1107.4,70,,,percent of total billed charges,70% of total billed charges,1186.5,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1210.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,711.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1107.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,949.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1107.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,759.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,711.9,4825.85,
BIOPSY NEEDLES,5547000E,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
BX TRAY,5547000E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
US GUIDED NDLE PLACEMENT,5547000E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
LIVER BIOPSY,5547000E,CDM,360,RC,47000,HCPCS,Outpatient,,,1582,949.2,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1107.4,70,,,percent of total billed charges,70% of total billed charges,1186.5,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1265.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1210.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,711.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1107.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,949.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1107.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,759.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,711.9,4825.85,
LIVER ABCESS DRAINAGE,5547011,CDM,360,RC,49405,HCPCS,Outpatient,,,2100,1260,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges,1575,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1680,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1606.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,945,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1260,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1470,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1008,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1890,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,945,4825.85,
HIP ARTHROGRA INJ LT,5547093,CDM,360,RC,27093,HCPCS,Outpatient,,,246,147.6,,44.28,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,44.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,172.2,70,,,percent of total billed charges,70% of total billed charges,184.5,75,,,percent of total billed charges,75% of total billed charges,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,172.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,246,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,221.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.28,930.49,
BX TRAY,5547093E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLUORO GUIDANCE,5547093E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,5547093E,CDM,322,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
HIP ARTHROGRA INJ RT,5547093RT,CDM,360,RC,27093,HCPCS,Outpatient,,,246,147.6,,44.28,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,44.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,172.2,70,,,percent of total billed charges,70% of total billed charges,184.5,75,,,percent of total billed charges,75% of total billed charges,123,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,196.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,147.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,188.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,172.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,147.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,172.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,246,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,221.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.28,930.49,
BX TRAY,5547093RTE,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLUORO GUIDANCE,5547093RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,5547093RTE,CDM,322,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
SIJ INJ ARTHROGR/ANESTH,5547096,CDM,360,RC,27096,HCPCS,Outpatient,,,1002,601.2,,180.36,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,180.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1107.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,701.4,70,,,percent of total billed charges,70% of total billed charges,751.5,75,,,percent of total billed charges,75% of total billed charges,501,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,801.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,601.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,766.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,701.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,601.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,701.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1002,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,901.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.36,1107.9,
IVC FILTER REMOVAL,5547193,CDM,360,RC,37193,HCPCS,Outpatient,,,3200,1920,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,9586.95,
GOOSE NECK SNARE,5547193E,CDM,272,RC,,,Outpatient,,,534.5,320.7,,96.21,18,,,percent of total billed charges,pays at 18% of total charges,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.25,50,,,percent of total billed charges,pays at 50% of total billed charges,374.15,70,,,percent of total billed charges,70% of total billed charges,400.88,75,,,percent of total billed charges,75% of total billed charges,267.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,427.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,374.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,320.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,374.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,481.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.76,534.5,
GUIDEWIRES,5547193E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
BAG DECANTER,5547193E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5547193E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
IVC FILTER REMOVAL,5547193E,CDM,360,RC,37193,HCPCS,Outpatient,,,3200,1920,,9586.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges,2400,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2560,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.62,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.33,103,,,Fee Schedule,103% of CMS OPPS Rate,2448,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1920,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2240,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1536,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2880,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,9586.95,
STENT PERPHRL OPEN/PERC VEIN,5547238,CDM,360,RC,37238,HCPCS,Outpatient,,,11480.8,6888.48,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,8036.56,70,,,percent of total billed charges,70% of total billed charges,8610.6,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9184.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,8782.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,5166.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,8036.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6888.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,8036.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,5510.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10332.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,3565,34162.33,
EMBOLIZATION COIL ARTERY,5547242,CDM,761,RC,37242,HCPCS,Outpatient,,,18188,10912.8,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21001.18,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,13641,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14550.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,13913.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3133.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,8184.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12731.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10912.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6911.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12731.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8730.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,16369.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2850.06,34162.33,
EMBOLIZATION COIL TUMOR,5547243,CDM,761,RC,37243,HCPCS,Outpatient,,,18188,10912.8,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,20143.99,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,13641,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14550.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,13913.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3133.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,8184.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12731.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10912.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6911.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12731.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8730.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,16369.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2850.06,34162.33,
EMOLIZATION COIL HEMMORAGE,5547244,CDM,761,RC,37244,HCPCS,Outpatient,,,18188,10912.8,,34162.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9650.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,21429.78,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,13641,75,,,percent of total billed charges,75% of total billed charges,17370.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,14550.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33776.32,350,,,Fee Schedule,350% of CMS OPPS Rate,9843.37,103,,,Fee Schedule,103% of CMS OPPS Rate,13913.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3133.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,8184.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,12731.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10912.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,6911.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,12731.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,22195.86,100,,,Fee Schedule,100% of CMS OPPS Rate,8730.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,16369.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2850.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9650.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2850.06,34162.33,
PTA VENOUS,5547248,CDM,360,RC,37248,HCPCS,Outpatient,,,5360,3216,,16784.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4741.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8812.64,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3752,70,,,percent of total billed charges,70% of total billed charges,4020,75,,,percent of total billed charges,75% of total billed charges,8534.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4288,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16594.61,350,,,Fee Schedule,350% of CMS OPPS Rate,4836.13,103,,,Fee Schedule,103% of CMS OPPS Rate,4100.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2412,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3752,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3216,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3752,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10905.03,100,,,Fee Schedule,100% of CMS OPPS Rate,2572.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4824,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,4741.31,100,,,Fee Schedule,100% of CMS OPPS Rate,2412,16784.25,
KNEE ARTHRO INJECT LT,5547370,CDM,360,RC,27369,HCPCS,Outpatient,,,170.4,102.24,,30.67,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,30.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.28,70,,,percent of total billed charges,70% of total billed charges,127.8,75,,,percent of total billed charges,75% of total billed charges,85.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,119.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,170.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.67,657,
KNEE ARTHRO INJECT RT,5547370RT,CDM,360,RC,27369,HCPCS,Outpatient,,,170.4,102.24,,30.67,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,30.67,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.28,70,,,percent of total billed charges,70% of total billed charges,127.8,75,,,percent of total billed charges,75% of total billed charges,85.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,136.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.24,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,119.28,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.79,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,170.4,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,153.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.67,657,
BX TRAY,5547370RTE,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLUORO GUIDANCE,5547370RTE,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
Draining or injecting medication into a major joint/bursa without ultrasound,5547370RTE,CDM,322,RC,20610,HCPCS,Outpatient,,,807.2,484.32,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,565.04,70,,,percent of total billed charges,70% of total billed charges,605.4,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,645.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,617.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,363.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,484.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,565.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,387.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,726.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,875,
PERC. CHOLECYSTOSTOMY,5547490,CDM,360,RC,47490,HCPCS,Outpatient,,,3262,1957.2,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2283.4,70,,,percent of total billed charges,70% of total billed charges,2446.5,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3262,103,,,Fee Schedule,103% of CMS OPPS Rate,2495.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1467.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2283.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1957.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2283.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2935.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1467.9,11398.68,
DRAIN POUCH NBPS-100,5547490E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
GUIDEWIRES,5547490E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
PERCUTAN SET N-PAS-100,5547490E,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
BAG DECANTER,5547490E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5547490E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
FLEXIMA NEPHROSTOMY CATH,5547490E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
US GUIDED NDLE PLACEMENT,5547490E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
RAD GUIDANCE ABCESS DRAIN,5547490E,CDM,360,RC,75989,HCPCS,Outpatient,,,435.6,261.36,,78.41,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,78.41,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.92,70,,,percent of total billed charges,70% of total billed charges,326.7,75,,,percent of total billed charges,75% of total billed charges,217.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,348.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,333.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,261.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,165.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,304.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,435.6,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,392.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.41,435.6,
PERC. CHOLECYSTOSTOMY,5547490E,CDM,360,RC,47490,HCPCS,Outpatient,,,3262,1957.2,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2283.4,70,,,percent of total billed charges,70% of total billed charges,2446.5,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2609.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3262,103,,,Fee Schedule,103% of CMS OPPS Rate,2495.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1467.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2283.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1957.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2283.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2935.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1467.9,11398.68,
CHOLANGIO INJ EXIS CATH,5547504,CDM,360,RC,47531,HCPCS,Outpatient,,,6437.3,3862.38,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4506.11,70,,,percent of total billed charges,70% of total billed charges,4827.98,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5149.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4924.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2896.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4506.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3862.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4506.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3089.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5793.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,11398.68,
CHOLANGIO INJ EXIS CATH,5547504E,CDM,360,RC,47531,HCPCS,Outpatient,,,6437.3,3862.38,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4506.11,70,,,percent of total billed charges,70% of total billed charges,4827.98,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5149.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,4924.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2896.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4506.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3862.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4506.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3089.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,5793.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,11398.68,
INJ CONTRAST EXISTING CAT,5547505,CDM,360,RC,36598,HCPCS,Outpatient,,,311.52,186.91,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,218.06,70,,,percent of total billed charges,70% of total billed charges,233.64,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,249.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,238.31,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,140.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,218.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,218.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,149.53,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,280.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,140.18,664.77,
PERC DRAIN EXT INTR,5547510,CDM,360,RC,47533,HCPCS,Outpatient,,,3452,2071.2,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2416.4,70,,,percent of total billed charges,70% of total billed charges,2589,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2761.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,2640.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1553.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2416.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2071.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2416.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1656.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3106.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1553.4,11398.68,
BAG DECANTER,5547510E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
GLIDECATHS,5547510E,CDM,272,RC,,,Outpatient,,,184,110.4,,33.12,18,,,percent of total billed charges,pays at 18% of total charges,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,184,
GLIDEWIRES,5547510E,CDM,272,RC,C1769,HCPCS,Outpatient,,,169,101.4,,30.42,18,,,percent of total billed charges,pays at 18% of total charges,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,75,,,percent of total billed charges,75% of total billed charges,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
DRAIN POUCH NBPS-100,5547510E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
PERCUTAN SET N-PAS-100,5547510E,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
ANGIO PACK,5547510E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
GUIDEWIRES,5547510E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
FLEXIMA NEPHROSTOMY CATH,5547510E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
PERC DRAIN EXT INTR,5547510E,CDM,360,RC,47533,HCPCS,Outpatient,,,3452,2071.2,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2416.4,70,,,percent of total billed charges,70% of total billed charges,2589,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2761.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,2640.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1553.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2416.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2071.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2416.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1656.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3106.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1553.4,11398.68,
PERC DRAIN INT/EXT INTRO,5547511,CDM,360,RC,47534,HCPCS,Outpatient,,,4419.18,2651.51,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3976.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3093.43,70,,,percent of total billed charges,70% of total billed charges,3314.39,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3535.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3380.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1988.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3093.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2651.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3093.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2121.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3977.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1988.63,11398.68,
DRAIN POUCH NBPS-100,5547511E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
DRAINAGE CATH,5547511E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
GLIDECATHS,5547511E,CDM,272,RC,,,Outpatient,,,184,110.4,,33.12,18,,,percent of total billed charges,pays at 18% of total charges,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,184,
GLIDEWIRES,5547511E,CDM,272,RC,C1769,HCPCS,Outpatient,,,169,101.4,,30.42,18,,,percent of total billed charges,pays at 18% of total charges,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,75,,,percent of total billed charges,75% of total billed charges,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
GUIDEWIRES,5547511E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
PERCUTAN SET N-PAS-100,5547511E,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
ANGIO PACK,5547511E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5547511E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
US GUIDED NDLE PLACEMENT,5547511E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
INT/EXT DRAIN S/I,5547511E,CDM,360,RC,47534,HCPCS,Outpatient,,,952.56,571.54,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,952.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3976.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,666.79,70,,,percent of total billed charges,70% of total billed charges,714.42,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,762.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,952.56,103,,,Fee Schedule,103% of CMS OPPS Rate,728.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,428.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,666.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,571.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,666.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,457.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,952.56,100,,,Fee Schedule,100% of CMS OPPS Rate,857.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,428.65,11398.68,
PERC DRAIN INT/EXT INTRO,5547511E,CDM,360,RC,47534,HCPCS,Outpatient,,,4419.18,2651.51,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3976.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3093.43,70,,,percent of total billed charges,70% of total billed charges,3314.39,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3535.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3380.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1988.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3093.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2651.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3093.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2121.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3977.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1988.63,11398.68,
CHANGE PERC BILI CATH,5547525,CDM,360,RC,47536,HCPCS,Outpatient,,,1592.64,955.58,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1592.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5579.43,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1114.85,70,,,percent of total billed charges,70% of total billed charges,1194.48,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1274.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,1592.64,103,,,Fee Schedule,103% of CMS OPPS Rate,1218.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,716.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1114.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,955.58,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1114.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,764.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1592.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1433.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,716.69,11398.68,
REMOVE BILIARY DRAIN,5547537,CDM,360,RC,47537,HCPCS,Outpatient,,,1644.05,986.43,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1150.84,70,,,percent of total billed charges,70% of total billed charges,1233.04,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1315.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,1257.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,739.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1150.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,986.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1150.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,789.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1479.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,739.82,2656.66,
BILIARY W/O STENT,5547555,CDM,360,RC,47555,HCPCS,Outpatient,,,3452,2071.2,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2416.4,70,,,percent of total billed charges,70% of total billed charges,2589,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2761.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,2640.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1553.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2416.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2071.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2416.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1656.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3106.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,1553.4,11398.68,
PERC DIL BILI STRICT STNT,5547556,CDM,360,RC,47556,HCPCS,Outpatient,,,4419.18,2651.51,,16773.81,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4419.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9151.97,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3093.43,70,,,percent of total billed charges,70% of total billed charges,3314.39,75,,,percent of total billed charges,75% of total billed charges,8529.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3535.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16584.27,350,,,Fee Schedule,350% of CMS OPPS Rate,4419.18,103,,,Fee Schedule,103% of CMS OPPS Rate,3380.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1988.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3093.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2651.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3093.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10898.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2121.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4419.18,100,,,Fee Schedule,100% of CMS OPPS Rate,3977.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1988.63,16773.81,
IVC FILTER PLACEMENT,5547620,CDM,360,RC,37191,HCPCS,Outpatient,,,4271,2562.6,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4271,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2989.7,70,,,percent of total billed charges,70% of total billed charges,3203.25,75,,,percent of total billed charges,75% of total billed charges,8410.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4271,103,,,Fee Schedule,103% of CMS OPPS Rate,3267.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2989.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2562.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2989.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2050.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4271,100,,,Fee Schedule,100% of CMS OPPS Rate,3843.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.95,16540.84,
MICROPUNCTURE INTRODU SET,5547620E,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
ANGIO PACK,5547620E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BAG DECANTER,5547620E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
GUIDEWIRES,5547620E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
6FR VENACAVE FILTER,5547620E,CDM,278,RC,C1880,HCPCS,Outpatient,,,3302.5,1981.5,,594.45,18,,,percent of total billed charges,pays at 18% of total charges,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.75,70,,,percent of total billed charges,70% of total billed charges,2476.88,75,,,percent of total billed charges,75% of total billed charges,1651.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2642,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1981.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3302.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,569.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2311.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1981.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1254.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2311.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.5,3302.5,
IVC FILTER PLACEMENT,5547620E,CDM,360,RC,37191,HCPCS,Outpatient,,,4271,2562.6,,16540.84,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,4271,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8695.83,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2989.7,70,,,percent of total billed charges,70% of total billed charges,3203.25,75,,,percent of total billed charges,75% of total billed charges,8410.59,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3416.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16353.94,350,,,Fee Schedule,350% of CMS OPPS Rate,4271,103,,,Fee Schedule,103% of CMS OPPS Rate,3267.32,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2989.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2562.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2895,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2989.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2050.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,4271,100,,,Fee Schedule,100% of CMS OPPS Rate,3843.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,4672.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.95,16540.84,
ANKLE ARTHRO INJECT LT,5547648,CDM,360,RC,27648,HCPCS,Outpatient,,,220,132,,39.6,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,39.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,930.49,
ANKLE ARTHRO INJECT RT,5547648RT,CDM,360,RC,27648,HCPCS,Outpatient,,,220,132,,39.6,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,39.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,930.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges,165,75,,,percent of total billed charges,75% of total billed charges,110,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,176,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,168.3,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,154,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,220,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,198,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.6,930.49,
BX PANCREAS PERC NEEDLE,5548102,CDM,360,RC,48102,HCPCS,Outpatient,,,1600,960,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2748.5,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,4825.85,
BONE MARROW BIOPSY LT,5548221,CDM,360,RC,38221,HCPCS,Outpatient,,,4221,2532.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2954.7,70,,,percent of total billed charges,70% of total billed charges,3165.75,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3229.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1899.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2954.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2532.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2954.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2026.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3798.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4825.85,
BX TRAY,5548221E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLUORO GUIDANCE,5548221E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
BONE MARROW BIOPSY LT,5548221E,CDM,360,RC,38221,HCPCS,Outpatient,,,4221,2532.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2954.7,70,,,percent of total billed charges,70% of total billed charges,3165.75,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3229.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1899.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2954.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2532.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2954.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2026.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3798.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4825.85,
BONE MARROW BIOPSY,5548221T,CDM,360,RC,38221,HCPCS,Outpatient,,,630,378,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,630,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,630,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,630,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,4825.85,
BONE MARROW BIOPSY/ ASP,5548223,CDM,360,RC,38222,HCPCS,Outpatient,,,7110,4266,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1236.82,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4977,70,,,percent of total billed charges,70% of total billed charges,5332.5,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5688,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2395.39,103,,,Fee Schedule,103% of CMS OPPS Rate,5439.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3199.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4977,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4266,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4977,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3412.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,6399,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.82,8313.44,
PELVIC ABSCESS DRAINAGE,5548823,CDM,360,RC,26990,HCPCS,Outpatient,,,2245.6,1347.36,,9579.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2706.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2245.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5393.36,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1571.92,70,,,percent of total billed charges,70% of total billed charges,1684.2,75,,,percent of total billed charges,75% of total billed charges,4870.93,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1796.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9471.28,350,,,Fee Schedule,350% of CMS OPPS Rate,2245.6,103,,,Fee Schedule,103% of CMS OPPS Rate,1717.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1571.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1347.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1571.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2245.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2021.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.52,9579.52,
PERITONEAL DRAINAGE (PERC,5549021,CDM,360,RC,49406,HCPCS,Outpatient,,,1600,960,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,720,4825.85,
CHIBA NEEDLE,5549052,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
NEEDLE-PERCUT-195326,5549057,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
RETROPERITONEAL (PERC),5549061,CDM,360,RC,49060,HCPCS,Outpatient,,,1600,960,,1600,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1600,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1600,100,,,Fee Schedule,pays at line item charges due to Status Indicator C on the CMS APC fee schedule,800,50,,,percent of total billed charges,pays at 50% of total billed charges,1120,70,,,percent of total billed charges,70% of total billed charges,1200,75,,,percent of total billed charges,75% of total billed charges,1600,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1600,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1600,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1224,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,720,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,960,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1571,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1120,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,768,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1440,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,100,,,Fee Schedule,100% of CMS OPPS Rate,720,1600,
PERCUTAN SET N-PAS-100,5549065,CDM,272,RC,,,Outpatient,,,207,124.2,,37.26,18,,,percent of total billed charges,pays at 18% of total charges,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,103.5,50,,,percent of total billed charges,pays at 50% of total billed charges,144.9,70,,,percent of total billed charges,70% of total billed charges,155.25,75,,,percent of total billed charges,75% of total billed charges,103.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,165.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.36,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,124.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,207,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,186.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,207,
PERITONEOCENTESIS INITIAL,5549080,CDM,360,RC,49083,HCPCS,Outpatient,,,1641,984.6,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1148.7,70,,,percent of total billed charges,70% of total billed charges,1230.75,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1312.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,1255.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,738.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1148.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1148.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,787.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,738.45,2656.66,
BX TRAY,5549080E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
PERITONEOCENTESIS INITIAL,5549080E,CDM,360,RC,49083,HCPCS,Outpatient,,,1641,984.6,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1148.7,70,,,percent of total billed charges,70% of total billed charges,1230.75,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1312.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,1255.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,738.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1148.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1148.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,787.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,738.45,2656.66,
PERITONEOCENTESIS SUBSEQ,5549081,CDM,360,RC,49083,HCPCS,Outpatient,,,830.5,498.3,,2656.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,750.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1515.9,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,581.35,70,,,percent of total billed charges,70% of total billed charges,622.88,75,,,percent of total billed charges,75% of total billed charges,1350.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,664.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2626.64,350,,,Fee Schedule,350% of CMS OPPS Rate,765.48,103,,,Fee Schedule,103% of CMS OPPS Rate,635.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,373.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,581.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,498.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,581.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1726.08,100,,,Fee Schedule,100% of CMS OPPS Rate,398.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,747.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,750.47,100,,,Fee Schedule,100% of CMS OPPS Rate,373.73,2656.66,
AMPLATZ,5549155,CDM,272,RC,,,Outpatient,,,528,316.8,,95.04,18,,,percent of total billed charges,pays at 18% of total charges,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,95.04,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,264,50,,,percent of total billed charges,pays at 50% of total billed charges,369.6,70,,,percent of total billed charges,70% of total billed charges,396,75,,,percent of total billed charges,75% of total billed charges,264,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,422.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,316.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,403.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,369.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,316.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,200.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,369.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,475.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,82.74,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.74,528,
AMPLATZ SS EXC 46-520,5549156,CDM,270,RC,,,Outpatient,,,661.5,396.9,,119.07,18,,,percent of total billed charges,pays at 18% of total charges,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,119.07,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.75,50,,,percent of total billed charges,pays at 50% of total billed charges,463.05,70,,,percent of total billed charges,70% of total billed charges,496.13,75,,,percent of total billed charges,75% of total billed charges,330.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,529.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,506.05,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.68,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,463.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,396.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,251.37,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,463.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,661.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,595.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.66,661.5,
PERC RETROPERI BX,5549181,CDM,360,RC,60100,HCPCS,Outpatient,,,568.8,341.28,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,568.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,398.16,70,,,percent of total billed charges,70% of total billed charges,426.6,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,455.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,568.8,103,,,Fee Schedule,103% of CMS OPPS Rate,435.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,255.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,398.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,341.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,398.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,273.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,568.8,100,,,Fee Schedule,100% of CMS OPPS Rate,511.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,255.96,2088.52,
GASTRO SET GIAS-100,5549201,CDM,270,RC,,,Outpatient,,,177.5,106.5,,31.95,18,,,percent of total billed charges,pays at 18% of total charges,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.95,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,88.75,50,,,percent of total billed charges,pays at 50% of total billed charges,124.25,70,,,percent of total billed charges,70% of total billed charges,133.13,75,,,percent of total billed charges,75% of total billed charges,88.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,142,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,135.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.45,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,124.25,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,177.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,159.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.81,177.5,
GASTRO SET WOGS - 100,5549202,CDM,270,RC,,,Outpatient,,,344.5,206.7,,62.01,18,,,percent of total billed charges,pays at 18% of total charges,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.01,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,172.25,50,,,percent of total billed charges,pays at 50% of total billed charges,241.15,70,,,percent of total billed charges,70% of total billed charges,258.38,75,,,percent of total billed charges,75% of total billed charges,172.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,275.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,206.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,263.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,241.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,206.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,130.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,241.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,344.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,310.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,53.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.98,344.5,
NEPHROURETERAL STENT,5549212,CDM,272,RC,C1758,HCPCS,Outpatient,,,260.5,156.3,,46.89,18,,,percent of total billed charges,pays at 18% of total charges,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.35,70,,,percent of total billed charges,70% of total billed charges,195.38,75,,,percent of total billed charges,75% of total billed charges,130.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,208.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,199.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,182.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,260.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,234.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.82,260.5,
DRAIN POUCH NBPS-100,5549221,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
GUIDEWIRES,5549247,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
GLIDEWIRES,5549249,CDM,272,RC,C1769,HCPCS,Outpatient,,,169,101.4,,30.42,18,,,percent of total billed charges,pays at 18% of total charges,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,30.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.75,75,,,percent of total billed charges,75% of total billed charges,84.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,169,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,152.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.48,169,
GLIDECATHS,5549251,CDM,272,RC,,,Outpatient,,,184,110.4,,33.12,18,,,percent of total billed charges,pays at 18% of total charges,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,184,
BIOPSY NEEDLES,5549252,CDM,272,RC,,,Outpatient,,,186,111.6,,33.48,18,,,percent of total billed charges,pays at 18% of total charges,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.48,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,93,50,,,percent of total billed charges,pays at 50% of total billed charges,130.2,70,,,percent of total billed charges,70% of total billed charges,139.5,75,,,percent of total billed charges,75% of total billed charges,93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,148.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,142.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,70.68,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,186,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,167.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.15,186,
ANGIO PACK,5549253,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
BX TRAY,5549254,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
INTRODUCES SHEATH (SHORT),5549261,CDM,272,RC,,,Outpatient,,,80,48,,14.4,18,,,percent of total billed charges,pays at 18% of total charges,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,40,50,,,percent of total billed charges,pays at 50% of total billed charges,56,70,,,percent of total billed charges,70% of total billed charges,60,75,,,percent of total billed charges,75% of total billed charges,40,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,61.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,30.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,80,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,12.54,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.54,80,
INTRODUCER SHEATH (LONG),5549262,CDM,272,RC,,,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75.5,50,,,percent of total billed charges,pays at 50% of total billed charges,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
FLEXIMA NEPHROSTOMY CATH,5549265,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
GOOSE NECK SNARE,5549266,CDM,272,RC,,,Outpatient,,,534.5,320.7,,96.21,18,,,percent of total billed charges,pays at 18% of total charges,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,267.25,50,,,percent of total billed charges,pays at 50% of total billed charges,374.15,70,,,percent of total billed charges,70% of total billed charges,400.88,75,,,percent of total billed charges,75% of total billed charges,267.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,427.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,320.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,408.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,374.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,320.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,374.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,481.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.76,534.5,
COONS DILATORS,5549268,CDM,272,RC,,,Outpatient,,,41,24.6,,7.38,18,,,percent of total billed charges,pays at 18% of total charges,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.5,50,,,percent of total billed charges,pays at 50% of total billed charges,28.7,70,,,percent of total billed charges,70% of total billed charges,30.75,75,,,percent of total billed charges,75% of total billed charges,20.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,15.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,28.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,41,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,36.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.42,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,41,
MICROPUNCTURE INTRODU SET,5549269,CDM,272,RC,,,Outpatient,,,100,60,,18,18,,,percent of total billed charges,pays at 18% of total charges,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,50,50,,,percent of total billed charges,pays at 50% of total billed charges,70,70,,,percent of total billed charges,70% of total billed charges,75,75,,,percent of total billed charges,75% of total billed charges,50,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,80,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,90,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,100,
TRIPLE LUMEN CATH,5549278,CDM,272,RC,C1751,HCPCS,Outpatient,,,151,90.6,,27.18,18,,,percent of total billed charges,pays at 18% of total charges,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.7,70,,,percent of total billed charges,70% of total billed charges,113.25,75,,,percent of total billed charges,75% of total billed charges,75.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,115.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,151,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.66,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.66,151,
G.J. TUBE,5549279,CDM,272,RC,,,Outpatient,,,660.5,396.3,,118.89,18,,,percent of total billed charges,pays at 18% of total charges,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.25,50,,,percent of total billed charges,pays at 50% of total billed charges,462.35,70,,,percent of total billed charges,70% of total billed charges,495.38,75,,,percent of total billed charges,75% of total billed charges,330.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,528.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,505.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,462.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,396.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,462.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,660.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,594.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.5,660.5,
GUIDEWIRES,5549279E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
GLIDECATHS,5549279E,CDM,272,RC,,,Outpatient,,,184,110.4,,33.12,18,,,percent of total billed charges,pays at 18% of total charges,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,92,50,,,percent of total billed charges,pays at 50% of total billed charges,128.8,70,,,percent of total billed charges,70% of total billed charges,138,75,,,percent of total billed charges,75% of total billed charges,92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,147.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,140.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,110.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,128.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,184,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,165.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.83,184,
BAG DECANTER,5549279E,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5549279E,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
US GUIDED NDLE PLACEMENT,5549279E,CDM,402,RC,76942,HCPCS,Outpatient,,,696.96,418.18,,125.45,18,,,percent of total billed charges,pays at 18% of total charges,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,125.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.87,70,,,percent of total billed charges,70% of total billed charges,522.72,75,,,percent of total billed charges,75% of total billed charges,348.48,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,557.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,533.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,120.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.63,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,418.18,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,487.87,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,696.96,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,627.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,696.96,
FLUORO GUIDANCE,5549279E,CDM,320,RC,77002,HCPCS,Outpatient,,,582.01,349.21,,104.76,18,,,percent of total billed charges,pays at 18% of total charges,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,104.76,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.41,70,,,percent of total billed charges,70% of total billed charges,436.51,75,,,percent of total billed charges,75% of total billed charges,291.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,465.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,445.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.28,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,349.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,407.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,582.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,523.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.2,582.01,
G.J. TUBE,5549279E,CDM,272,RC,,,Outpatient,,,660.5,396.3,,118.89,18,,,percent of total billed charges,pays at 18% of total charges,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,118.89,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,330.25,50,,,percent of total billed charges,pays at 50% of total billed charges,462.35,70,,,percent of total billed charges,70% of total billed charges,495.38,75,,,percent of total billed charges,75% of total billed charges,330.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,528.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,505.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.23,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,462.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,396.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,250.99,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,462.35,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,660.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,594.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,103.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.5,660.5,
DUAL LUMEN PICC LINE,5549288,CDM,272,RC,,,Outpatient,,,248,148.8,,44.64,18,,,percent of total billed charges,pays at 18% of total charges,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,124,50,,,percent of total billed charges,pays at 50% of total billed charges,173.6,70,,,percent of total billed charges,70% of total billed charges,186,75,,,percent of total billed charges,75% of total billed charges,124,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.72,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,173.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,248,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.86,248,
MICROPORT,5549291,CDM,278,RC,C1788,HCPCS,Outpatient,,,1167.65,700.59,,210.18,18,,,percent of total billed charges,pays at 18% of total charges,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,210.18,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.36,70,,,percent of total billed charges,70% of total billed charges,875.74,75,,,percent of total billed charges,75% of total billed charges,583.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,934.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,700.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1167.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,201.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.44,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,817.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,700.59,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,443.71,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,817.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1167.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1167.65,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,182.97,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.97,1167.65,
BIOPSY BRUSH,5549293,CDM,272,RC,,,Outpatient,,,150,90,,27,18,,,percent of total billed charges,pays at 18% of total charges,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,75,50,,,percent of total billed charges,pays at 50% of total billed charges,105,70,,,percent of total billed charges,70% of total billed charges,112.5,75,,,percent of total billed charges,75% of total billed charges,75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,120,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,114.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,105,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,150,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,135,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.51,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,150,
6FR VENACAVE FILTER,5549294,CDM,278,RC,C1880,HCPCS,Outpatient,,,3302.5,1981.5,,594.45,18,,,percent of total billed charges,pays at 18% of total charges,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,594.45,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2311.75,70,,,percent of total billed charges,70% of total billed charges,2476.88,75,,,percent of total billed charges,75% of total billed charges,1651.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,2642,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1981.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3302.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,569.02,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1486.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2311.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1981.5,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1254.95,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2311.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,3302.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,517.5,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.5,3302.5,
PTA BALLOON NON LAS CATH,5549296,CDM,272,RC,C1725,HCPCS,Outpatient,,,536.5,321.9,,96.57,18,,,percent of total billed charges,pays at 18% of total charges,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.55,70,,,percent of total billed charges,70% of total billed charges,402.38,75,,,percent of total billed charges,75% of total billed charges,268.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,429.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,375.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,375.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,536.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,482.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.07,536.5,
DRAIN PLCMNT VISCERAL/LUNG/KIDNEY,5549405,CDM,360,RC,49405,HCPCS,Outpatient,,,2120,1272,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1484,70,,,percent of total billed charges,70% of total billed charges,1590,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1696,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1621.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,954,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1484,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1272,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1484,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1017.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,954,4825.85,
GUIDEWIRES,5549405E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
NEEDLE-PERCUT-195326,5549405E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
BX TRAY,5549405E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
DRAIN POUCH NBPS-100,5549405E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
FLEXIMA NEPHROSTOMY CATH,5549405E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
DRAIN PLCMNT VISCERAL/LUNG/KIDNEY,5549405E,CDM,360,RC,49405,HCPCS,Outpatient,,,2120,1272,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1484,70,,,percent of total billed charges,70% of total billed charges,1590,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1696,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1621.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,954,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1484,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1272,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1484,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1017.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1908,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,954,4825.85,
DRAIN PLCMNT RETROPERIT/PERITONEAL,5549406,CDM,360,RC,49406,HCPCS,Outpatient,,,2226,1335.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1558.2,70,,,percent of total billed charges,70% of total billed charges,1669.5,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1780.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1702.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1558.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1335.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1558.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.7,4825.85,
DRAIN POUCH NBPS-100,5549406E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
NEEDLE-PERCUT-195326,5549406E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
BX TRAY,5549406E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
GUIDEWIRES,5549406E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
FLEXIMA NEPHROSTOMY CATH,5549406E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
DRAIN PLCMNT RETROPERIT/PERITONEAL,5549406E,CDM,360,RC,49406,HCPCS,Outpatient,,,2226,1335.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1558.2,70,,,percent of total billed charges,70% of total billed charges,1669.5,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1780.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1702.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1558.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1335.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1558.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.7,4825.85,
DRAIN PLCMNT TRANS VAG/TRANS RECTAL,5549407,CDM,360,RC,49407,HCPCS,Outpatient,,,1314.4,788.64,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1314.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2583.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,920.08,70,,,percent of total billed charges,70% of total billed charges,985.8,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1051.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1314.4,103,,,Fee Schedule,103% of CMS OPPS Rate,1005.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,591.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,920.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,920.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,630.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1314.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1182.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,591.48,4825.85,
DRAIN POUCH NBPS-100,5549407E,CDM,272,RC,,,Outpatient,,,46,27.6,,8.28,18,,,percent of total billed charges,pays at 18% of total charges,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.28,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23,50,,,percent of total billed charges,pays at 50% of total billed charges,32.2,70,,,percent of total billed charges,70% of total billed charges,34.5,75,,,percent of total billed charges,75% of total billed charges,23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.7,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,32.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,46,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,41.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.21,46,
GUIDEWIRES,5549407E,CDM,272,RC,C1769,HCPCS,Outpatient,,,48.5,29.1,,8.73,18,,,percent of total billed charges,pays at 18% of total charges,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.73,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,75,,,percent of total billed charges,75% of total billed charges,24.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,38.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,33.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,48.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,43.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.6,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,48.5,
NEEDLE-PERCUT-195326,5549407E,CDM,272,RC,,,Outpatient,,,49.5,29.7,,8.91,18,,,percent of total billed charges,pays at 18% of total charges,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.91,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.75,50,,,percent of total billed charges,pays at 50% of total billed charges,34.65,70,,,percent of total billed charges,70% of total billed charges,37.13,75,,,percent of total billed charges,75% of total billed charges,24.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,49.5,
BX TRAY,5549407E,CDM,272,RC,,,Outpatient,,,102,61.2,,18.36,18,,,percent of total billed charges,pays at 18% of total charges,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51,50,,,percent of total billed charges,pays at 50% of total billed charges,71.4,70,,,percent of total billed charges,70% of total billed charges,76.5,75,,,percent of total billed charges,75% of total billed charges,51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,81.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,78.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,38.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,71.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,102,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,91.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.98,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,102,
FLEXIMA NEPHROSTOMY CATH,5549407E,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
DRAIN PLCMNT TRANS VAG/TRANS RECTAL,5549407E,CDM,360,RC,49407,HCPCS,Outpatient,,,1314.4,788.64,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1314.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2583.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,920.08,70,,,percent of total billed charges,70% of total billed charges,985.8,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1051.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1314.4,103,,,Fee Schedule,103% of CMS OPPS Rate,1005.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,591.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,920.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,788.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,920.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,630.91,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1314.4,100,,,Fee Schedule,100% of CMS OPPS Rate,1182.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,591.48,4825.85,
FIDICIAL MARKER PLACEMENT ABDOMEN,5549411,CDM,360,RC,49411,HCPCS,Outpatient,,,1534,920.4,,4314.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1218.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2419.52,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1073.8,70,,,percent of total billed charges,70% of total billed charges,1150.5,75,,,percent of total billed charges,75% of total billed charges,2193.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1227.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4265.8,350,,,Fee Schedule,350% of CMS OPPS Rate,1243.17,103,,,Fee Schedule,103% of CMS OPPS Rate,1173.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1073.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,920.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1073.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2803.24,100,,,Fee Schedule,100% of CMS OPPS Rate,736.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.3,4314.56,
INSERT TUN IP CATH PERC,5549418,CDM,360,RC,49418,HCPCS,Outpatient,,,5040,3024,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3528,70,,,percent of total billed charges,70% of total billed charges,3780,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3855.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2268,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3528,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3024,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3528,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2419.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,4536,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,11398.68,
DRAINAGE CATH,5549418EXP,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
BAG DECANTER,5549418EXP,CDM,272,RC,,,Outpatient,,,9.5,5.7,,1.71,18,,,percent of total billed charges,pays at 18% of total charges,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.71,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.75,50,,,percent of total billed charges,pays at 50% of total billed charges,6.65,70,,,percent of total billed charges,70% of total billed charges,7.13,75,,,percent of total billed charges,75% of total billed charges,4.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,7.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.61,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,6.65,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,9.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,8.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,9.5,
ANGIO PACK,5549418EXP,CDM,272,RC,,,Outpatient,,,317,190.2,,57.06,18,,,percent of total billed charges,pays at 18% of total charges,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,158.5,50,,,percent of total billed charges,pays at 50% of total billed charges,221.9,70,,,percent of total billed charges,70% of total billed charges,237.75,75,,,percent of total billed charges,75% of total billed charges,158.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,253.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,242.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,120.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,221.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,317,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,285.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.67,317,
INSERT TUN IP CATH PERC,5549418EXP,CDM,360,RC,49418,HCPCS,Outpatient,,,5040,3024,,11398.68,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3219.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5935.56,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3528,70,,,percent of total billed charges,70% of total billed charges,3780,75,,,percent of total billed charges,75% of total billed charges,5795.94,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4032,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11269.88,350,,,Fee Schedule,350% of CMS OPPS Rate,3284.36,103,,,Fee Schedule,103% of CMS OPPS Rate,3855.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2268,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3528,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3024,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3528,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,7405.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2419.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,4536,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,3219.96,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,11398.68,
REMOVE TUN IP CATH PERC,5549422,CDM,360,RC,49422,HCPCS,Outpatient,,,2520,1512,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2520,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1764,70,,,percent of total billed charges,70% of total billed charges,1890,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2016,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2520,103,,,Fee Schedule,103% of CMS OPPS Rate,1927.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1764,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1512,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1764,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2520,100,,,Fee Schedule,100% of CMS OPPS Rate,2268,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1134,9586.96,
REMOVE TUN IP CATH PERC,5549422E,CDM,360,RC,49422,HCPCS,Outpatient,,,3150,1890,,9586.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2708.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5082.45,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2205,70,,,percent of total billed charges,70% of total billed charges,2362.5,75,,,percent of total billed charges,75% of total billed charges,4874.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2520,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9478.63,350,,,Fee Schedule,350% of CMS OPPS Rate,2762.34,103,,,Fee Schedule,103% of CMS OPPS Rate,2409.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1417.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2205,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1890,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2028,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2205,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1512,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2835,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,2708.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1417.5,9586.96,
CHG DRAINAGE CATH/ABC CYS,5549423,CDM,360,RC,49406,HCPCS,Outpatient,,,1769.6,1061.76,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1238.72,70,,,percent of total billed charges,70% of total billed charges,1327.2,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1415.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1353.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,796.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1238.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1061.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1238.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,849.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,796.32,4825.85,
CON INJ ABC/CYST EXIST CA,5549424,CDM,360,RC,49424,HCPCS,Outpatient,,,142,85.2,,25.56,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,25.56,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,99.4,70,,,percent of total billed charges,70% of total billed charges,106.5,75,,,percent of total billed charges,75% of total billed charges,71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,113.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,108.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,99.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,85.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,99.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,142,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,127.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,657,
CONVERT GASTROSTOMY TO GAS-JEJUNOSTOMY,5549446,CDM,360,RC,49446,HCPCS,Outpatient,,,1756,1053.6,,5604.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1583.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2910.31,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1229.2,70,,,percent of total billed charges,70% of total billed charges,1317,75,,,percent of total billed charges,75% of total billed charges,2849.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1404.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5541.47,350,,,Fee Schedule,350% of CMS OPPS Rate,1614.94,103,,,Fee Schedule,103% of CMS OPPS Rate,1343.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,790.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1229.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1053.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,1229.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3641.53,100,,,Fee Schedule,100% of CMS OPPS Rate,842.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1580.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.28,100,,,Fee Schedule,100% of CMS OPPS Rate,790.2,5604.8,
INJ CONTRAST EXISTING G TUBE,5549465,CDM,360,RC,49465,HCPCS,Outpatient,,,262.2,157.32,,751.51,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,473.66,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,183.54,70,,,percent of total billed charges,70% of total billed charges,196.65,75,,,percent of total billed charges,75% of total billed charges,382.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,209.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,743.02,350,,,Fee Schedule,350% of CMS OPPS Rate,216.53,103,,,Fee Schedule,103% of CMS OPPS Rate,200.58,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,117.99,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,657,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,183.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,488.27,100,,,Fee Schedule,100% of CMS OPPS Rate,125.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,235.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,212.29,100,,,Fee Schedule,100% of CMS OPPS Rate,117.99,751.51,
INDEFLATOR NON LAS CATH,5549550,CDM,272,RC,C1725,HCPCS,Outpatient,,,536.5,321.9,,96.57,18,,,percent of total billed charges,pays at 18% of total charges,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,96.57,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.55,70,,,percent of total billed charges,70% of total billed charges,402.38,75,,,percent of total billed charges,75% of total billed charges,268.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,429.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,321.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,410.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,92.44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,375.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,321.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,203.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,375.55,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,536.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,482.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.07,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.07,536.5,
DRAINAGE CATH,5549551,CDM,272,RC,C1729,HCPCS,Outpatient,,,229,137.4,,41.22,18,,,percent of total billed charges,pays at 18% of total charges,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.22,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.3,70,,,percent of total billed charges,70% of total billed charges,171.75,75,,,percent of total billed charges,75% of total billed charges,114.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,183.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,175.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,39.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,137.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,87.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,160.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,229,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,206.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,35.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.88,229,
CATH PERITONEAL DRAINAGE,5549552,CDM,272,RC,C1729,HCPCS,Outpatient,,,1430,858,,257.4,18,,,percent of total billed charges,pays at 18% of total charges,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,257.4,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001,70,,,percent of total billed charges,70% of total billed charges,1072.5,75,,,percent of total billed charges,75% of total billed charges,715,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,1144,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,858,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1093.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,246.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1001,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,858,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,543.4,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1001,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1430,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,1287,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,224.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.08,1430,
VESSEL MAPPING HEMO ACCESS,5549553,CDM,320,RC,G0365,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.37,364,
TRAY BALLON SACROPLASTY,5549858,CDM,272,RC,,,Outpatient,,,5021,3012.6,,903.78,18,,,percent of total billed charges,pays at 18% of total charges,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,903.78,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2510.5,50,,,percent of total billed charges,pays at 50% of total billed charges,3514.7,70,,,percent of total billed charges,70% of total billed charges,3765.75,75,,,percent of total billed charges,75% of total billed charges,2510.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4016.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3841.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2259.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3012.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,1907.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3514.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2410.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,5021,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,4518.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,786.79,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.79,5021,
Incision and drainage of abscess; simple or single and complex or multiple,7250002,CDM,516,RC,10060,HCPCS,Outpatient,,,297.44,178.46,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,297.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.08,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.03,581.14,
INC & DRNG ABSCESS CMPLCTD OR MULTI,7250003,CDM,516,RC,10061,HCPCS,Outpatient,,,525,315,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,525,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.75,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,420,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,401.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,236.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,315,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,367.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,252,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,472.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,525,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,199.5,1200.6,
INC & DRNG PILONIDAL CYST,7250004,CDM,516,RC,10080,HCPCS,Outpatient,,,164.8,98.88,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,164.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.6,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,164.8,103,,,Fee Schedule,103% of CMS OPPS Rate,126.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,74.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,62.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,115.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,79.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.8,100,,,Fee Schedule,100% of CMS OPPS Rate,148.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,62.62,2088.52,
INCISION & RMVL FB SUBQ SMPL,7250005,CDM,516,RC,10120,HCPCS,Outpatient,,,596,357.6,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,596,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,476.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,455.94,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,268.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,357.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,226.48,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,417.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,286.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,536.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,596,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,226.48,1200.6,
"Incision and drainage of hematoma, seroma or fluid collection",7250006,CDM,516,RC,10140,HCPCS,Outpatient,,,1276.8,766.08,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1276.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1276.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.6,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1021.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1276.8,103,,,Fee Schedule,103% of CMS OPPS Rate,976.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,574.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,893.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,766.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,485.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,893.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,612.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1276.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1149.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1276.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,485.18,4825.85,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",7250007,CDM,516,RC,10160,HCPCS,Outpatient,,,402.16,241.3,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,402.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.62,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,307.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,180.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,152.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,361.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,152.82,1200.6,
"Removal of skin tags, multiple fibrocutaneous tags, any area",7250008,CDM,516,RC,11200,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,181.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,581.14,
Separation and removal of the entire nail plate or a portion of nail plate,7250010,CDM,516,RC,11730,HCPCS,Outpatient,,,158.61,95.17,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,158.61,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,158.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,158.61,103,,,Fee Schedule,103% of CMS OPPS Rate,121.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,71.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,111.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,76.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.61,100,,,Fee Schedule,100% of CMS OPPS Rate,142.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,158.61,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.27,581.14,
INGROWN NAIL,7250012,CDM,516,RC,11765,HCPCS,Outpatient,,,128.3,76.98,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,128.3,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.23,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,128.3,103,,,Fee Schedule,103% of CMS OPPS Rate,98.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,57.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.98,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.3,100,,,Fee Schedule,100% of CMS OPPS Rate,115.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,128.3,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,1200.61,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",7250013,CDM,516,RC,12001,HCPCS,Outpatient,,,375,225,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,375,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.25,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,300,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,286.88,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,168.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,142.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,262.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,180,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,337.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,142.5,581.14,
SMPL RPR SCLP/AXILL/TR 2.6CM - 7.5CM,7250014,CDM,516,RC,12002,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,581.14,
SMPL RPR SCLP/AXILL/TR 7.6CM - 12.5CM,7250015,CDM,516,RC,12004,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,581.14,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",7250016,CDM,516,RC,12011,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,581.14,
SMPL RPR WND 2.6CM - 5.0CM,7250017,CDM,516,RC,12013,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,581.14,
SMPL RPR WND 5.1CM - 7.5CM,7250018,CDM,516,RC,12014,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,581.14,
SMPL RPR WND 7.6 CM TO 12.5 CM,7250019,CDM,516,RC,12015,HCPCS,Outpatient,,,356.84,214.1,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.63,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,272.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,214.1,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,249.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,171.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,321.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,135.6,581.14,
INTRMDT RPR SCLP/AXILL/TRNK/EXT 2.5 OR <,7250020,CDM,516,RC,12031,HCPCS,Outpatient,,,202.29,121.37,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,202.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.72,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,161.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,202.29,103,,,Fee Schedule,103% of CMS OPPS Rate,154.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,91.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,76.87,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,141.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,97.1,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,202.29,100,,,Fee Schedule,100% of CMS OPPS Rate,182.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,76.87,1200.6,
INTRMDT RPR SCLP/AXILL/TRNK/EXT 2.6-7.5,7250021,CDM,516,RC,12032,HCPCS,Outpatient,,,252.56,151.54,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,252.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,252.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.42,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,202.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,252.56,103,,,Fee Schedule,103% of CMS OPPS Rate,193.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,113.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,95.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.79,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,121.23,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252.56,100,,,Fee Schedule,100% of CMS OPPS Rate,227.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,95.97,1200.6,
INTRMDT RPR SCLP/AXILL/TRNK/EXT 7.6-12.5,7250022,CDM,516,RC,12034,HCPCS,Outpatient,,,326.8,196.08,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,326.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,326.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.1,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,261.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,326.8,103,,,Fee Schedule,103% of CMS OPPS Rate,250,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,147.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,228.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,124.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,228.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,156.86,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,326.8,100,,,Fee Schedule,100% of CMS OPPS Rate,294.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,326.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,124.18,1200.6,
INTRMDT RPR SCLP/AXILL/TRNK/EXT 12.6-20.,7250023,CDM,516,RC,12035,HCPCS,Outpatient,,,479,287.4,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,479,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.25,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,383.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,366.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,215.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,287.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,182.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,335.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,229.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,431.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,479,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,182.02,1200.6,
INTRMDT RPR NCK/HNDS/FET/GNTLIA <=2.5,7250024,CDM,516,RC,12041,HCPCS,Outpatient,,,233.6,140.16,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,233.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.2,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,233.6,103,,,Fee Schedule,103% of CMS OPPS Rate,178.7,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,105.12,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,163.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,140.16,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,88.77,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,163.52,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,112.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,233.6,100,,,Fee Schedule,100% of CMS OPPS Rate,210.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,233.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,88.77,1200.61,
INTRMDT RPR NCK/HNDS/FET/GNTLIA 2.6-7.5,7250025,CDM,516,RC,12042,HCPCS,Outpatient,,,277.2,166.32,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,277.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,277.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.9,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,221.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,277.2,103,,,Fee Schedule,103% of CMS OPPS Rate,212.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,124.74,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,105.34,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,133.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,277.2,100,,,Fee Schedule,100% of CMS OPPS Rate,249.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,105.34,1200.6,
INTRMDT RPR FACE/EAR/EYELD/NOS/LIP <2.5,7250028,CDM,516,RC,12051,HCPCS,Outpatient,,,437.8,262.68,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,437.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.35,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,350.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,334.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,197.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,166.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,210.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,394.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,166.36,1200.6,
INTRMDT REPR FACE/EAR/EYELID/NOSE/LIP,7250029,CDM,516,RC,12052,HCPCS,Outpatient,,,437.8,262.68,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,437.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.35,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,350.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,334.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,197.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,262.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,166.36,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,306.46,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,210.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,394.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,437.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,166.36,1200.6,
INTRMDT REPR FACE/EAR/EYELID/NOSE/LIP,7250031,CDM,516,RC,12054,HCPCS,Outpatient,,,784.65,470.79,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,784.65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.49,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,627.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,600.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,353.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,549.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,470.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,298.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,549.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,376.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,706.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,784.65,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,298.17,1200.61,
CMPLX RPR EYELDS/ NOSE/ LIP 2.6-7.5 CM,7250036,CDM,516,RC,13152,HCPCS,Outpatient,,,462.8,277.68,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,462.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,462.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.1,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,370.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,462.8,103,,,Fee Schedule,103% of CMS OPPS Rate,354.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,208.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,323.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,277.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,175.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,323.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,222.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,462.8,100,,,Fee Schedule,100% of CMS OPPS Rate,416.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,462.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,175.86,1869.61,
BURN FIRST DEGREE LOCAL AREA INITIAL TX,7250037,CDM,516,RC,16000,HCPCS,Outpatient,,,100.53,60.32,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,100.53,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,100.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.4,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,80.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,100.53,103,,,Fee Schedule,103% of CMS OPPS Rate,76.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,45.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,70.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,38.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,70.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,48.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,100.53,100,,,Fee Schedule,100% of CMS OPPS Rate,90.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,100.53,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,38.2,581.14,
BURN TX SMALL LESS THAN 5 PRCNT BS AREA,7250038,CDM,516,RC,16020,HCPCS,Outpatient,,,178,106.8,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,178,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.5,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,142.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,136.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,80.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,124.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,106.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,67.64,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,124.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,85.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,160.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,178,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,67.64,581.14,
BURN TX MED 5 TO 10 PRCNT BS AREA,7250039,CDM,516,RC,16025,HCPCS,Outpatient,,,189.2,113.52,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,189.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.9,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,151.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,144.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,85.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,132.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,113.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,71.9,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,132.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,90.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,170.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,189.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,71.9,581.14,
BURN TX LRG GRTR THAN 10 PRCNT BS AREA,7250040,CDM,516,RC,16030,HCPCS,Outpatient,,,264.5,158.7,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,264.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,264.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.38,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,211.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,264.5,103,,,Fee Schedule,103% of CMS OPPS Rate,202.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,119.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,185.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,100.51,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,185.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,126.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,264.5,100,,,Fee Schedule,100% of CMS OPPS Rate,238.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,264.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,100.51,1200.6,
Injection of medication into a tendon or ligament,7250041,CDM,516,RC,20550,HCPCS,Outpatient,,,397.38,238.43,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,397.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.04,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,304,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,151,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,151,875,
Draining or injecting medication into a small joint/bursa without ultrasound,7250042,CDM,516,RC,20600,HCPCS,Outpatient,,,317.9,190.74,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.43,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.8,875,
Draining or injecting medication into a large joint/bursa without ultrasound,7250043,CDM,516,RC,20605,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,875,
Draining or injecting medication into a major joint/bursa without ultrasound,7250044,CDM,516,RC,20610,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,317.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,317.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,875,
NOSE FRACTURE SIMPLE,7250045,CDM,516,RC,21310,HCPCS,Outpatient,,,140.02,84.01,,25.2,18,,,percent of total billed charges,pays at 18% of total charges,140.02,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,25.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.02,75,,,percent of total billed charges,75% of total billed charges,70.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,112.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,84.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,107.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,98.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,84.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,53.21,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,98.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,140.02,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,126.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,140.02,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,140.02,
CLSD TX CLAVICLE FX WO MANIP,7250047,CDM,516,RC,23500,HCPCS,Outpatient,,,371.2,222.72,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,371.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.4,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,296.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,283.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,167.04,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,259.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,141.06,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,259.84,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,178.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,334.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,371.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,141.06,666.19,
CLAVICLE FX CLSD TX  W MANIP,7250048,CDM,516,RC,23505,HCPCS,Outpatient,,,884.8,530.88,,4616.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,884.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,884.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.6,75,,,percent of total billed charges,75% of total billed charges,2347.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,707.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4564.42,350,,,Fee Schedule,350% of CMS OPPS Rate,884.8,103,,,Fee Schedule,103% of CMS OPPS Rate,676.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,398.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,619.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,530.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,336.22,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,619.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2999.47,100,,,Fee Schedule,100% of CMS OPPS Rate,424.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,884.8,100,,,Fee Schedule,100% of CMS OPPS Rate,796.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,884.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,336.22,4616.59,
CLSD TX PRXML HUMERAL FX WO MANIPLTN,7250049,CDM,516,RC,23600,HCPCS,Outpatient,,,334.4,200.64,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,334.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.8,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,267.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,255.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,150.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,234.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,127.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,234.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,160.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,300.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,127.07,666.19,
CLSD TX HUMERAL SHAFT FX WO MANIPLTN,7250050,CDM,516,RC,24500,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
CLSD TX RADIAL SHAFT FX WO MANIPLTN,7250051,CDM,516,RC,25500,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
CLSD TX ULNAR SHAFT FX WO MANIPLTN,7250052,CDM,516,RC,25530,HCPCS,Outpatient,,,334.4,200.64,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,334.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.8,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,267.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,255.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,150.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,234.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,200.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,127.07,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,234.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,160.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,300.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,334.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,127.07,666.19,
CLSD TX RADL AND ULNR SHFT FX WO MANIPLN,7250053,CDM,516,RC,25560,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
CLSD TX DISTAL RADIAL FX WO MANIPLTN,7250054,CDM,516,RC,25600,HCPCS,Outpatient,,,507.2,304.32,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,507.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.4,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,405.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,388.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,228.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,355.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,304.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,192.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,355.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,243.46,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,456.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,507.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,666.19,
INCSN AND DRNG FINGER ABSCESS SIMPLE,7250055,CDM,516,RC,26010,HCPCS,Outpatient,,,341,204.6,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,341,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,129.58,581.14,
INCSN AND DRNG FINGER ABSCESS COMPLEX,7250056,CDM,516,RC,26011,HCPCS,Outpatient,,,1263.18,757.91,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1263.18,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1263.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,947.39,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1010.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1263.18,103,,,Fee Schedule,103% of CMS OPPS Rate,966.33,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,568.43,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,884.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,757.91,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,480.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,884.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,606.33,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1263.18,100,,,Fee Schedule,100% of CMS OPPS Rate,1136.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1263.18,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,480.01,4825.85,
CLSD TX METACARPAL FX WO MANIP EA BONE,7250057,CDM,516,RC,26600,HCPCS,Outpatient,,,268.8,161.28,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,268.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,102.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,102.14,666.19,
CLSD TX METACARPAL FX W MANIP EA BONE,7250058,CDM,516,RC,26605,HCPCS,Outpatient,,,609.6,365.76,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,609.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.2,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,487.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,466.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,274.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,426.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,365.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,231.65,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,426.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,292.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,548.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,609.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,666.19,
CLSD TX PHALANGEAL SHAFT FX WO MANIP,7250059,CDM,516,RC,26720,HCPCS,Outpatient,,,268.8,161.28,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,268.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.6,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,215.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,205.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,120.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,102.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,188.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,129.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,241.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,268.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,102.14,666.19,
CLSD TX PHALANGEAL SHAFT FX W MANIP,7250060,CDM,516,RC,26725,HCPCS,Outpatient,,,354.4,212.64,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,354.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.8,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,283.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,271.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,159.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,248.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,212.64,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,134.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,248.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,170.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,318.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,354.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,134.67,666.19,
CLSD TX TIBIAL SHAFT FX WO MANIP,7250061,CDM,516,RC,27750,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
REMOVAL FOREIGN BODY FOOT,7250062,CDM,516,RC,28190,HCPCS,Outpatient,,,1016,609.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1016,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,777.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,457.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,487.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,914.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.08,2088.52,
CLSD TX METATARSAL FX WO MANIP EA BONE,7250063,CDM,516,RC,28470,HCPCS,Outpatient,,,262.8,157.68,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,262.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.1,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,210.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,201.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,118.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,183.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,157.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.86,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,183.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,126.14,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,236.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,262.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,99.86,666.19,
CLSD TX FX GREAT TOE WO MANIPLTN,7250064,CDM,516,RC,28490,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
CLSD TX FX PHALANX WO MANIPLTN EACH,7250065,CDM,516,RC,28510,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
SPICA CAST (WRIST),7250066,CDM,516,RC,29085,HCPCS,Outpatient,,,205.73,123.44,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,205.73,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.3,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,164.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,157.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,92.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,78.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,144.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,98.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,185.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.73,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,78.18,469.08,
APPLY LONG ARM SPLINT,7250067,CDM,516,RC,29105,HCPCS,Outpatient,,,341,204.6,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,341,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,129.58,469.08,
APPLY SHORT ARM SPLINT,7250068,CDM,516,RC,29125,HCPCS,Outpatient,,,341,204.6,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,341,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,373.66,
APPLY FINGER SPLINT,7250069,CDM,516,RC,29130,HCPCS,Outpatient,,,115,69,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,115,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.25,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,87.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,51.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.7,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,55.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,103.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,115,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,43.7,373.66,
STRAPPING ELBOW OR WRIST,7250070,CDM,516,RC,29260,HCPCS,Outpatient,,,105.62,63.37,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,105.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.22,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,80.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,47.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,95.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.14,184.98,
STRAPPING FINGER OR HAND,7250071,CDM,516,RC,29280,HCPCS,Outpatient,,,105.62,63.37,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,105.62,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.22,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,84.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,80.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,47.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,73.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,73.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,50.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,95.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.62,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,40.14,184.98,
SHORT LEG CAST,7250072,CDM,516,RC,29405,HCPCS,Outpatient,,,310,186,,772.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,310,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,392.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.35,350,,,Fee Schedule,350% of CMS OPPS Rate,222.45,103,,,Fee Schedule,103% of CMS OPPS Rate,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,117.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,501.63,100,,,Fee Schedule,100% of CMS OPPS Rate,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,310,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,117.8,772.08,
SHORT LEG WALKING CAST,7250073,CDM,516,RC,29425,HCPCS,Outpatient,,,329.28,197.57,,772.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,329.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.96,75,,,percent of total billed charges,75% of total billed charges,392.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,263.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.35,350,,,Fee Schedule,350% of CMS OPPS Rate,222.45,103,,,Fee Schedule,103% of CMS OPPS Rate,251.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,148.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,125.13,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,230.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,501.63,100,,,Fee Schedule,100% of CMS OPPS Rate,158.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,296.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,125.13,772.08,
APPLY LONG LEG SPLINT,7250074,CDM,516,RC,29505,HCPCS,Outpatient,,,255.2,153.12,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,255.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.4,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,195.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,114.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,122.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,229.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.98,469.08,
APPLY SHORT LEG SPLINT,7250075,CDM,516,RC,29515,HCPCS,Outpatient,,,255.2,153.12,,469.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,255.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,132.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.4,75,,,percent of total billed charges,75% of total billed charges,238.51,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,463.78,350,,,Fee Schedule,350% of CMS OPPS Rate,135.15,103,,,Fee Schedule,103% of CMS OPPS Rate,195.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,114.84,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.12,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.64,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,304.76,100,,,Fee Schedule,100% of CMS OPPS Rate,122.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,229.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of CMS OPPS Rate,96.98,469.08,
REMOVAL OF FOREIGN BODY FROM NOSE,7250076,CDM,516,RC,30300,HCPCS,Outpatient,,,170.32,102.19,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,170.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.74,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,130.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,76.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,81.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.72,373.66,
NASAL HEMORRHAGE CNTRL ANTERIOR,7250077,CDM,516,RC,30901,HCPCS,Outpatient,,,341,204.6,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,341,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.75,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,272.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,260.87,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,204.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,129.58,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,238.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,163.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,306.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,341,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,373.66,
NASAL HEMORRHAGE CNTRL POSTERIOR,7250078,CDM,516,RC,30905,HCPCS,Outpatient,,,135.94,81.56,,373.65,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,135.94,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.96,75,,,percent of total billed charges,75% of total billed charges,189.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,108.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,103.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,61.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,95.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,81.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,51.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,95.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,65.25,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,122.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,135.94,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,51.66,373.65,
Collection of venous blood by venipuncture,7250079,CDM,300,RC,36415,HCPCS,Outpatient,,,12.75,7.65,,30.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,8.93,70,,,percent of total billed charges,70% of total billed charges,,,,,Other,Not Separately reimbursable,15.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.99,350,,,Fee Schedule,350% of CMS OPPS Rate,8.74,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.75,230,,,Fee Schedule,230% of CMS OPPS Rate,6.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,6.12,30.33,
INCSN AND DRNG DENTAL STRCTRS,7250080,CDM,516,RC,41800,HCPCS,Outpatient,,,160.8,96.48,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,160.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.6,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,128.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,123.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,72.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,61.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,77.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,144.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,61.1,373.66,
Ultrasound of bladder to measure urine capacity,7250083,CDM,516,RC,51798,HCPCS,Outpatient,,,211,126.6,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,211,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.25,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,168.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,161.42,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,94.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,80.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,147.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,101.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,189.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,211,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,211,
REMOVAL FB FROM EAR,7250087,CDM,516,RC,69200,HCPCS,Outpatient,,,289.08,173.45,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,289.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.81,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,231.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,221.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,130.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,202.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,109.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,202.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,138.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,260.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,289.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,373.66,
Removal of ear wax from one or both ears,7250088,CDM,516,RC,69210,HCPCS,Outpatient,,,132.88,79.73,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,132.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.66,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,106.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,101.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,59.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,93.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,50.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,93.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,63.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,119.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,132.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,50.49,184.98,
INCSN AND DRNG PERIRECTAL ABSCESS,7250089,CDM,516,RC,46040,HCPCS,Outpatient,,,2226.38,1335.83,,3485.03,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2226.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,984.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,984.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.79,75,,,percent of total billed charges,75% of total billed charges,1772.04,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1781.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3445.65,350,,,Fee Schedule,350% of CMS OPPS Rate,1004.15,103,,,Fee Schedule,103% of CMS OPPS Rate,1703.18,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.87,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1558.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1335.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,846.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1558.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2264.28,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.66,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2226.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,984.47,100,,,Fee Schedule,100% of CMS OPPS Rate,846.02,3485.03,
Immunization administration by a medical assistant or nurse,7250090,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
TD ADULT,7250091,CDM,636,RC,90714,HCPCS,Outpatient,,,210.15,126.09,,37.83,18,,,percent of total billed charges,pays at 18% of total charges,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,37.83,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.08,50,,,percent of total billed charges,pays at 50% of total billed charges,147.11,70,,,percent of total billed charges,70% of total billed charges,157.61,75,,,percent of total billed charges,75% of total billed charges,105.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,168.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,126.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,160.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.57,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,147.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.09,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.11,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.87,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,210.15,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,189.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.93,210.15,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",7250092,CDM,516,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,630,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",7250093,CDM,516,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,165,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,165,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,165,
INJECTION SQ OR IM,7250094,CDM,516,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,255.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,255.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,255.35,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",7250095,CDM,516,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,7250096,CDM,516,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,125,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,125,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,136.34,
DRAIN EXTERNAL EAR,7250097,CDM,516,RC,69000,HCPCS,Outpatient,,,356.38,213.83,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,356.38,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,356.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.29,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,285.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,356.38,103,,,Fee Schedule,103% of CMS OPPS Rate,272.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,160.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,249.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,213.83,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.47,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,171.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,356.38,100,,,Fee Schedule,100% of CMS OPPS Rate,320.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,356.38,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,160.37,2088.52,
"New patient office or other outpatient visit, typically 10 minutes",7250101,CDM,516,RC,99202,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"New patient office or other outpatient visit, typically 30 min",7250102,CDM,516,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,168.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
"New patient office of other outpatient visit, typically 45 min",7250103,CDM,516,RC,99204,HCPCS,Outpatient,,,389,233.4,,70.02,18,,,percent of total billed charges,pays at 18% of total charges,389,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,70.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.75,75,,,percent of total billed charges,75% of total billed charges,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,389,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.02,389,
"New patient office of other outpatient visit, typically 60 min",7250104,CDM,516,RC,99205,HCPCS,Outpatient,,,306.04,183.62,,55.09,18,,,percent of total billed charges,pays at 18% of total charges,306.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,55.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.53,75,,,percent of total billed charges,75% of total billed charges,153.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,306.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.09,306.04,
Outpatient visit of established patient not requiring a physician,7250105,CDM,516,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,123,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,123,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
Outpatient visit of established patient requiring a physician,7250106,CDM,516,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7250107,CDM,516,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,160,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,160,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",7250108,CDM,516,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,168.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,168.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
"Established patient office or other outpatient, visit typically 40 minutes",7250109,CDM,516,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,40.26,18,,,percent of total billed charges,pays at 18% of total charges,223.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,111.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,223.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.26,223.68,
HYDRATION INFUSION INITIAL HR,7250110,CDM,516,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,630,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,630,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,664.77,
CONCURRENT NONCHEMO INFUSION ADDL HR,7250112,CDM,516,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,64.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,64.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.58,64.35,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,7250113,CDM,516,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,275,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,275,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,275,
INTUBATION ENDOTRACHEAL,7250115,CDM,516,RC,31500,HCPCS,Outpatient,,,556.56,333.94,,668.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,556.56,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.42,75,,,percent of total billed charges,75% of total billed charges,340.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,445.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.27,350,,,Fee Schedule,350% of CMS OPPS Rate,192.71,103,,,Fee Schedule,103% of CMS OPPS Rate,425.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,250.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,389.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,333.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,389.59,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,434.54,100,,,Fee Schedule,100% of CMS OPPS Rate,267.15,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,500.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,556.56,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,668.83,
REPAIR LIP,7250116,CDM,516,RC,40650,HCPCS,Outpatient,,,1529.28,917.57,,1470.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1529.28,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,415.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,415.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1146.96,75,,,percent of total billed charges,75% of total billed charges,747.52,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1223.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1453.53,350,,,Fee Schedule,350% of CMS OPPS Rate,423.59,103,,,Fee Schedule,103% of CMS OPPS Rate,1169.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,688.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1070.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,917.57,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1070.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,955.17,100,,,Fee Schedule,100% of CMS OPPS Rate,734.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,1376.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1529.28,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,100,,,Fee Schedule,100% of CMS OPPS Rate,415.29,1529.28,
RMVL EMBEDDED FRGN BDY EXT EYE,7250117,CDM,516,RC,65210,HCPCS,Outpatient,,,336,201.6,,1215.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,336,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,343.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,336,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,75,,,percent of total billed charges,75% of total billed charges,617.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,268.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1201.37,350,,,Fee Schedule,350% of CMS OPPS Rate,336,103,,,Fee Schedule,103% of CMS OPPS Rate,257.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,151.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,201.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,235.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,789.47,100,,,Fee Schedule,100% of CMS OPPS Rate,161.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,336,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,336,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,151.2,1215.1,
CRITICAL CARE,7250118,CDM,516,RC,99291,HCPCS,Outpatient,,,1665,999,,2470.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1665,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,697.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,697.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,1165.5,70,,,percent of total billed charges,70% of total billed charges,1248.75,75,,,percent of total billed charges,75% of total billed charges,1256.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1332,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2442.77,350,,,Fee Schedule,350% of CMS OPPS Rate,711.88,103,,,Fee Schedule,103% of CMS OPPS Rate,1273.73,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,749.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1165.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,999,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3099,100,,,Case rate,Pays based on per visit ,1165.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3407,100,,,Case rate,pays based on per visit rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1498.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1665,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,100,,,Fee Schedule,100% of CMS OPPS Rate,697.93,3407,
CLSD TX FX PHALANX W MANIPLTN EACH,7250122,CDM,516,RC,28515,HCPCS,Outpatient,,,232.68,139.61,,666.19,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,232.68,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.51,75,,,percent of total billed charges,75% of total billed charges,338.74,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,186.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,658.67,350,,,Fee Schedule,350% of CMS OPPS Rate,191.95,103,,,Fee Schedule,103% of CMS OPPS Rate,178,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,104.71,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,139.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,162.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,432.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,209.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,232.68,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,88.42,666.19,
CPR,7250126,CDM,516,RC,92950,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,685,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,260.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,685,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,901.29,
NG INSERTION,7250127,CDM,516,RC,43753,HCPCS,Outpatient,,,217.08,130.25,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,217.08,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,217.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.81,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,217.08,103,,,Fee Schedule,103% of CMS OPPS Rate,166.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,97.69,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.25,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,82.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.96,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,104.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,217.08,100,,,Fee Schedule,100% of CMS OPPS Rate,195.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,217.08,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,82.49,901.29,
TX VAGINAL BLEED,7250128,CDM,516,RC,57180,HCPCS,Outpatient,,,386.4,231.84,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,386.4,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.8,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,309.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,295.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,270.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,231.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,146.83,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,270.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,185.47,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,347.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,386.4,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,146.83,573.26,
CMPLX RPR TRUNK 1.1 TO 2.5 CM,7250129,CDM,516,RC,13100,HCPCS,Outpatient,,,684.84,410.9,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,684.84,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.63,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,547.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,523.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,308.18,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,410.9,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,260.24,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,479.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,328.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,616.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,260.24,1869.61,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",7250130,CDM,516,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,149,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,149,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,149,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",7250131,CDM,516,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,85.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,32.49,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,85.5,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,85.5,
EKG URGENT CARE,7250132,CDM,730,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,282.05,70,,,percent of total billed charges,70% of total billed charges,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,373,100,,,Case rate,Pays based on per visit ,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,373,
NEBULIZER TX INTIAL,7250133,CDM,410,RC,94640,HCPCS,Outpatient,,,280,168,,616.28,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,380.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196,70,,,percent of total billed charges,70% of total billed charges,210,75,,,percent of total billed charges,75% of total billed charges,313.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,224,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,609.32,350,,,Fee Schedule,350% of CMS OPPS Rate,177.57,103,,,Fee Schedule,103% of CMS OPPS Rate,214.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,48.24,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,126,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,313,100,,,Case rate,Pays based on per visit ,196,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,134.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,252,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.09,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,616.28,
REMOVAL FOREIGN BODY FOOT COMPLEX,7250143,CDM,516,RC,28193,HCPCS,Outpatient,,,1016,609.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1016,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1016,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1016,103,,,Fee Schedule,103% of CMS OPPS Rate,777.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,457.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,386.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,487.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1016,100,,,Fee Schedule,100% of CMS OPPS Rate,914.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,386.08,4825.85,
NURSE ONLY VISIT PRODUCTIVITY,7251000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INCISION & RMVL FB SUBQ CMPLCTD,7251121,CDM,516,RC,10121,HCPCS,Outpatient,,,2484.48,1490.69,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2484.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1863.36,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1987.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1900.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1739.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1490.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,944.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1739.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1192.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2236.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,944.1,4825.85,
SMPL RPR SCLP/AXILL/TRNK/EXT 20.1-30 CM,7252006,CDM,516,RC,12006,HCPCS,Outpatient,,,431.35,258.81,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,431.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.51,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,345.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,329.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,194.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,301.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,207.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,388.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,1200.61,
SMPL RPR SCLP/AXILL/TRNK/EXT >30 CM,7252007,CDM,516,RC,12007,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,181.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,581.14,
SMPL RPR WND 12.6 - 20 CM,7252016,CDM,516,RC,12016,HCPCS,Outpatient,,,181.48,108.89,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,181.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,181.48,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,1200.61,
SMPL RPR WND 20 - 30 CM,7252017,CDM,516,RC,12018,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,181.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,581.14,
SMPL RPR WND > 30 CM,7252018,CDM,516,RC,12018,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,181.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,181.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,581.14,
INTRMDT RPR SCLP/AXIL/TRNK/EXT 20.1-30CM,7252036,CDM,516,RC,12036,HCPCS,Outpatient,,,887.33,532.4,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,887.33,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.5,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,709.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,678.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,399.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,621.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,532.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,337.19,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,621.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,425.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,798.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,887.33,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,337.19,1869.61,
INTRMDT RPR SCLP/AXIL/TRNK/EXT > 30CM,7252037,CDM,516,RC,12037,HCPCS,Outpatient,,,913.95,548.37,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,913.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,913.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.46,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,731.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,913.95,103,,,Fee Schedule,103% of CMS OPPS Rate,699.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,411.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,639.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,548.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,347.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,639.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,438.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,913.95,100,,,Fee Schedule,100% of CMS OPPS Rate,822.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,347.3,5554.18,
INTRMDT RPR NCK/HNDS/FET/GNTL 20.1-30 CM,7252046,CDM,516,RC,12046,HCPCS,Outpatient,,,431.35,258.81,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,431.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,431.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.51,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,345.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,431.35,103,,,Fee Schedule,103% of CMS OPPS Rate,329.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,194.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,301.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,207.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of CMS OPPS Rate,388.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,1869.61,
INTRMDT RPR NCK/HNDS/FET/GNTL 20.1-30 CM,7252047,CDM,516,RC,12047,HCPCS,Outpatient,,,913.95,548.37,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,913.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,913.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.46,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,731.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,913.95,103,,,Fee Schedule,103% of CMS OPPS Rate,699.17,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,411.28,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,639.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,548.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,347.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,639.77,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,438.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,913.95,100,,,Fee Schedule,100% of CMS OPPS Rate,822.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,913.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,347.3,5554.18,
INTRMDT RPR FACE/EAR/EYELID/NOSE/LIP,7252056,CDM,516,RC,12056,HCPCS,Outpatient,,,431.35,258.81,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,431.35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.51,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,345.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,329.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,194.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,301.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,258.81,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,301.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,207.05,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,388.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,431.35,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,163.91,1200.61,
GLUCOSE MONITORING,7252962,CDM,300,RC,82962,HCPCS,Outpatient,,,11.25,6.75,,11.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges,8.44,75,,,percent of total billed charges,75% of total billed charges,5.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.48,350,,,Fee Schedule,350% of CMS OPPS Rate,3.34,102,,,Fee Schedule,102% of CMS OPPS Rate,8.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of UHC Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,7.54,230,,,Fee Schedule,230% of CMS OPPS Rate,5.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,11.61,
INCSN AND DRNG VULVA OR PERINEAL ABSCESS,7256405,CDM,516,RC,56405,HCPCS,Outpatient,,,410.55,246.33,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,410.55,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.91,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,328.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,270.72,103,,,Fee Schedule,103% of CMS OPPS Rate,314.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,184.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,287.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,246.33,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,156.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,287.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,197.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,369.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,410.55,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,156.01,939.58,
"New patient office or other outpatient visit, typically 10 minutes",7300002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
TENOTOMY-PERCUTANEOUS ACHILLES TENDON,7300003,CDM,510,RC,27605,HCPCS,Outpatient,,,4813.41,2888.05,,4616.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4813.41,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1304.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3610.06,75,,,percent of total billed charges,75% of total billed charges,2347.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3850.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4564.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1330.2,103,,,Fee Schedule,103% of CMS OPPS Rate,3682.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2166.03,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3369.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2888.05,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1829.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3369.39,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2999.47,100,,,Fee Schedule,100% of CMS OPPS Rate,2310.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,4332.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4813.41,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,4813.41,
Outpatient visit of established patient not requiring a physician,7300006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7300007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
NURSE ONLY VISIT,7309999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
"New patient office or other outpatient visit, typically 10 minutes",7330002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Outpatient visit of established patient not requiring a physician,7330006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7330007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7330008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",7331001,CDM,510,RC,11102,HCPCS,Outpatient,,,402.7,241.62,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,581.14,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); each separate/additional lesion",7331002,CDM,510,RC,11103,HCPCS,Outpatient,,,402.7,241.62,,72.49,18,,,percent of total billed charges,pays at 18% of total charges,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,201.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.1,402.7,
"PUNCH BIOPSY, SINGLE",7331003,CDM,510,RC,11104,HCPCS,Outpatient,,,402.7,241.62,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,1200.6,
PUNCH BIOPSY EACH ADDITIONAL,7331004,CDM,510,RC,11105,HCPCS,Outpatient,,,402.7,241.62,,72.49,18,,,percent of total billed charges,pays at 18% of total charges,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,201.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.1,402.7,
"INCISIONAL BIOPSY, SINGLE",7331005,CDM,510,RC,11106,HCPCS,Outpatient,,,716.8,430.08,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,573.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,548.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,272.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,344.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,645.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,112.32,1869.61,
INCISIONAL BIOPSY EACH ADDITIONAL,7331006,CDM,510,RC,11107,HCPCS,Outpatient,,,716.8,430.08,,129.02,18,,,percent of total billed charges,pays at 18% of total charges,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,75,,,percent of total billed charges,75% of total billed charges,358.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,548.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,716.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,645.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.32,716.8,
SHAVE LESION TRUNK/EXT 0.5CM OR LESS,7331042,CDM,761,RC,11300,HCPCS,Outpatient,,,128.28,76.97,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,96.21,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,128.28,103,,,Fee Schedule,103% of CMS OPPS Rate,98.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,57.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,61.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.28,100,,,Fee Schedule,100% of CMS OPPS Rate,115.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,20.1,1200.61,
SHAVE LESION< 0.5 CM FACE,7331050,CDM,761,RC,11310,HCPCS,Outpatient,,,155.68,93.41,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.76,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.68,103,,,Fee Schedule,103% of CMS OPPS Rate,119.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,74.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.68,100,,,Fee Schedule,100% of CMS OPPS Rate,140.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
Injections to remove up to 7 lesions on the skin,7331095,CDM,761,RC,11900,HCPCS,Outpatient,,,128.28,76.97,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,96.21,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,128.28,103,,,Fee Schedule,103% of CMS OPPS Rate,98.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,57.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,61.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.28,100,,,Fee Schedule,100% of CMS OPPS Rate,115.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.1,581.14,
Destruction of pre-cancerous lesion,7331133,CDM,761,RC,17000,HCPCS,Outpatient,,,155.68,93.41,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.76,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.68,103,,,Fee Schedule,103% of CMS OPPS Rate,119.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.68,100,,,Fee Schedule,100% of CMS OPPS Rate,140.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
Destruction of 2-14 pre-cancerous lesions,7331134,CDM,761,RC,17003,HCPCS,Outpatient,,,152,91.2,,27.36,18,,,percent of total billed charges,pays at 18% of total charges,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,27.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.19,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,23.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.82,152,
DEST PREMLGNT LESION 15 OR MORE,7331135,CDM,761,RC,17004,HCPCS,Outpatient,,,364.98,218.99,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,273.74,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,291.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,279.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,62.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,164.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,255.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,138.69,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,255.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,175.19,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,328.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,57.19,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,57.19,1200.6,
DEST VASCULAR LESION OVER 50 SQ CM,7331138,CDM,761,RC,17108,HCPCS,Outpatient,,,375.93,225.56,,5554.18,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,375.93,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,375.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3197.87,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,281.95,75,,,percent of total billed charges,75% of total billed charges,2824.15,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,300.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5491.42,350,,,Fee Schedule,350% of CMS OPPS Rate,375.93,103,,,Fee Schedule,103% of CMS OPPS Rate,287.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,169.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,263.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,225.56,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,142.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,263.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3608.64,100,,,Fee Schedule,100% of CMS OPPS Rate,180.45,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,375.93,100,,,Fee Schedule,100% of CMS OPPS Rate,338.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,375.93,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.98,100,,,Fee Schedule,100% of CMS OPPS Rate,142.85,5554.18,
Destruction of 1-14 common or plantar warts,7331139,CDM,761,RC,17110,HCPCS,Outpatient,,,155.7,93.42,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.78,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.7,103,,,Fee Schedule,103% of CMS OPPS Rate,119.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.7,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
DEST MALIG LSN TRK/EXTRM 0.5 CM OR LESS,7331142,CDM,510,RC,17260,HCPCS,Outpatient,,,186.2,111.72,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,142.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,83.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,89.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,167.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,29.18,581.14,
DEST MALIG LSN TRK/EXTRM 2.1 TO 3CM,7331145,CDM,510,RC,17263,HCPCS,Outpatient,,,186.2,111.72,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,142.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,83.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,89.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,167.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,29.18,581.14,
DEST MALIG LSN SP/HD/FT/GNT 0.5CM OR LES,7331147,CDM,761,RC,17270,HCPCS,Outpatient,,,186.2,111.72,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,139.65,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,142.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,83.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,89.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,167.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,29.18,581.14,
DEST MALIG LESION FACE 0.5CM OR LESS,7331152,CDM,510,RC,17280,HCPCS,Outpatient,,,186.2,111.72,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.65,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,148.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,142.44,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.08,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,83.79,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,111.72,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,130.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,89.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,167.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,29.18,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,29.18,581.14,
INJECTION SQ OR IM,7331596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
GLUCOSE MONITORING,7332962,CDM,300,RC,82962,HCPCS,Outpatient,,,11.25,6.75,,11.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3.26,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,6.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges,8.44,75,,,percent of total billed charges,75% of total billed charges,5.9,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.48,350,,,Fee Schedule,350% of CMS OPPS Rate,3.34,102,,,Fee Schedule,102% of CMS OPPS Rate,8.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,5.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of UHC Fee Schedule,7.88,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,7.54,230,,,Fee Schedule,230% of CMS OPPS Rate,5.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,10.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.26,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,11.61,
BIOPSY EXTERNAL EAR,7339100,CDM,510,RC,69100,HCPCS,Outpatient,,,329.2,197.52,,668.83,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,329.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,188.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.9,75,,,percent of total billed charges,75% of total billed charges,340.08,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,263.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,661.27,350,,,Fee Schedule,350% of CMS OPPS Rate,192.71,103,,,Fee Schedule,103% of CMS OPPS Rate,251.84,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,148.14,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,230.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,197.52,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,125.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,230.44,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,434.54,100,,,Fee Schedule,100% of CMS OPPS Rate,158.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,296.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,329.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,100,,,Fee Schedule,100% of CMS OPPS Rate,125.1,668.83,
NURSE ONLY VISIT,7339999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Outpatient visit of established patient not requiring a physician,7380006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7380007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7380008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
EKG PANEL,7381100,CDM,510,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,153.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,362.64,
Immunization administration by a medical assistant or nurse,7381585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7381586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
INJECTION SQ OR IM,7381596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
EVAL PACER W ADJUSTMENTS SNGL LEAD,7383279,CDM,480,RC,93279,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
EVAL PACER W ADJUSTMENTS DUAL LEAD,7383280,CDM,480,RC,93280,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
EVAL PACER W ADJUSTMENTS MULTI LEAD,7383281,CDM,480,RC,93281,HCPCS,Outpatient,,,62,37.2,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.72,1196,
EVAL DEFIB W ADJUSTMENTS SNGL LEAD,7383282,CDM,480,RC,93282,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
EVAL DEFIB W ADJUSTMENTS DUAL LEAD,7383283,CDM,480,RC,93283,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
EVAL DEFIB W ADJUSTMENTS MULTI LEAD,7383284,CDM,480,RC,93284,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
INTERROGATION PACEMAKER EVAL,7383288,CDM,480,RC,93288,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
INTERROGATION DEFIBRILLATOR EVAL,7383289,CDM,480,RC,93289,HCPCS,Outpatient,,,59.1,35.46,,112.63,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,31.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,76.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.37,70,,,percent of total billed charges,70% of total billed charges,44.33,75,,,percent of total billed charges,75% of total billed charges,57.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,47.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,111.36,350,,,Fee Schedule,350% of CMS OPPS Rate,32.45,103,,,Fee Schedule,103% of CMS OPPS Rate,45.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.18,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1196,100,,,Case rate,Pays based on per visit ,41.37,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.18,100,,,Fee Schedule,100% of CMS OPPS Rate,28.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,53.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.26,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,31.81,100,,,Fee Schedule,100% of CMS OPPS Rate,9.26,1196,
NURSE ONLY VISIT,738999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Outpatient visit of established patient not requiring a physician,7390006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7390007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7390008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Immunization administration by a medical assistant or nurse,7391585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7391586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
INJECTION SQ OR IM,7391596,CDM,940,RC,96372,HCPCS,Outpatient,,,87,52.2,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,60.9,70,,,percent of total billed charges,70% of total billed charges,65.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,69.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,66.56,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,39.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,60.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,41.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,78.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,39.15,217.13,
REMOVAL FRGN BODY NASAL,7410300,CDM,510,RC,30300,HCPCS,Outpatient,,,170.32,102.19,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,170.32,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.74,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,130.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,76.64,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.19,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.22,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,81.75,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,153.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,170.32,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.72,373.66,
NASAL HMRRHG SMPL,7410901,CDM,510,RC,30901,HCPCS,Outpatient,,,169.92,101.95,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,169.92,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.44,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,135.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,129.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,76.46,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.95,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.57,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.94,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,81.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,152.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,169.92,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,64.57,373.66,
"Flexible, fiberoptic diagnostic laryngoscopy",7411575,CDM,510,RC,31575,HCPCS,Outpatient,,,260.8,156.48,,575.25,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,260.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,162.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,162.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.6,75,,,percent of total billed charges,75% of total billed charges,292.5,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,568.75,350,,,Fee Schedule,350% of CMS OPPS Rate,165.74,103,,,Fee Schedule,103% of CMS OPPS Rate,199.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,117.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,99.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,182.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,373.74,100,,,Fee Schedule,100% of CMS OPPS Rate,125.18,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,234.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,260.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,162.5,100,,,Fee Schedule,100% of CMS OPPS Rate,99.1,575.25,
EAR EXAM W MICROSCOPE BINOCULAR,7412504,CDM,510,RC,92504,HCPCS,Outpatient,,,51.14,30.68,,9.21,18,,,percent of total billed charges,pays at 18% of total charges,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.21,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.36,75,,,percent of total billed charges,75% of total billed charges,25.57,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,40.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,39.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,35.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.68,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,19.43,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,35.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,51.14,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,46.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.01,51.14,
HEARING SCREENING,7412551,CDM,470,RC,92551,HCPCS,Outpatient,,,87.75,52.65,,15.8,18,,,percent of total billed charges,pays at 18% of total charges,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,43.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,100,,,Case rate,Pays based on per visit ,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,137,
INJECTION SQ OR IM,7416372,CDM,510,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,97.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
REMOVAL FRGN BODY EAR,7419200,CDM,510,RC,69200,HCPCS,Outpatient,,,289.08,173.45,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.81,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,231.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,221.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,49.81,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,130.09,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,202.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,173.45,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,109.85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,202.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,138.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,260.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.3,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,45.3,373.66,
CLINIC NEW PT LEVEL 1,7419201,CDM,510,RC,99201,HCPCS,Outpatient,,,117.37,70.42,,,,,,Other,Not Separately reimbursable,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,105.63,
"New patient office or other outpatient visit, typically 10 minutes",7419202,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,137.1,
"New patient office of other outpatient visit, typically 45 min",7419204,CDM,510,RC,99204,HCPCS,Outpatient,,,389,233.4,,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,350.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,350.1,
Removal of ear wax from one or both ears,7419210,CDM,510,RC,69210,HCPCS,Outpatient,,,115.85,69.51,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.89,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,88.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.96,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.13,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,44.02,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,81.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,55.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,104.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.15,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,18.15,184.98,
Outpatient visit of established patient not requiring a physician,7419211,CDM,510,RC,99211,HCPCS,Outpatient,,,123,73.8,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,110.7,
Outpatient visit of established patient requiring a physician,7419212,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,144,
"Established patient office or other outpatient visit, typically 15 minutes",7419213,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,144,
"Established patient office or other outpatient visit, typically 25 minutes",7419214,CDM,510,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,151.92,
"Established patient office or other outpatient, visit typically 40 minutes",7419215,CDM,510,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,201.31,
NURSE ONLY VISIT,7419999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Outpatient visit of established patient not requiring a physician,7420006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,105.63,
Outpatient visit of established patient requiring a physician,7420007,CDM,510,RC,99212,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,137.1,
"Established patient office or other outpatient visit, typically 15 minutes",7420008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,137.1,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",7420017,CDM,510,RC,97597,HCPCS,Outpatient,,,252.44,151.46,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.33,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,201.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,193.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,95.93,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.71,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,121.17,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,227.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.56,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,39.56,581.14,
SELECTIVE DEBRID OF WOUND EA ADD 20SQ CM,7420018,CDM,510,RC,97598,HCPCS,Outpatient,,,216,129.6,,,,,,Other,Not Separately reimbursable,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,172.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.2,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,129.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,82.08,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.2,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.68,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,194.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.85,194.4,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",7420060,CDM,510,RC,10160,HCPCS,Outpatient,,,402.16,241.3,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,402.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.62,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,307.65,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,180.97,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,152.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,361.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,402.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,152.82,1200.6,
Injection of medication into a tendon or ligament,7420550,CDM,510,RC,20550,HCPCS,Outpatient,,,397.38,238.43,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.04,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,304,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,151,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.27,875,
"PUNCH BIOPSY, SINGLE",7421003,CDM,510,RC,11104,HCPCS,Outpatient,,,402.7,241.62,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,1200.6,
DBRDMNT TO SUBQ 1ST 20 SQ CM OR LESS,7421033,CDM,510,RC,11042,HCPCS,Outpatient,,,459.8,275.88,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,459.8,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.85,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,367.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,351.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,206.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,321.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,275.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,174.72,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,321.86,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,220.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,413.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,459.8,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,174.72,1200.6,
"TENOTOMY, TOE, SINGLE TENDON",7421040,CDM,510,RC,28232,HCPCS,Outpatient,,,3481,2088.6,,4616.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,3481,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1304.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2610.75,75,,,percent of total billed charges,75% of total billed charges,2347.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,2784.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4564.42,350,,,Fee Schedule,350% of CMS OPPS Rate,1330.2,103,,,Fee Schedule,103% of CMS OPPS Rate,2662.97,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2436.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2088.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,2436.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2999.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1670.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,3132.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,3481,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.11,4616.59,
Separation and removal of the entire nail plate or a portion of nail plate,7421088,CDM,510,RC,11730,HCPCS,Outpatient,,,158.61,95.17,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,158.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,126.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,158.61,103,,,Fee Schedule,103% of CMS OPPS Rate,121.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,27.33,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,71.37,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,111.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.17,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,60.27,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,111.03,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,76.13,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.61,100,,,Fee Schedule,100% of CMS OPPS Rate,142.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.85,581.14,
REMOVAL OF NAIL & NAIL MATRIX PERMANENT,7421090,CDM,510,RC,11750,HCPCS,Outpatient,,,690.9,414.54,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,690.9,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,518.18,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,552.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,528.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,310.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,483.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,414.54,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,262.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,483.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,331.63,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,621.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,690.9,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,262.54,1200.6,
Destruction of 1-14 common or plantar warts,7421139,CDM,510,RC,17110,HCPCS,Outpatient,,,155.7,93.42,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.78,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.7,103,,,Fee Schedule,103% of CMS OPPS Rate,119.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.7,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
Draining or injecting medication into a large joint/bursa without ultrasound,7421203,CDM,510,RC,20605,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,875,
APPLY SHORT LEG CAST,7429405,CDM,510,RC,29405,HCPCS,Outpatient,,,310,186,,772.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,218.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.5,75,,,percent of total billed charges,75% of total billed charges,392.57,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,248,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,763.35,350,,,Fee Schedule,350% of CMS OPPS Rate,222.45,103,,,Fee Schedule,103% of CMS OPPS Rate,237.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,53.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,139.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,186,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,117.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,217,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,501.63,100,,,Fee Schedule,100% of CMS OPPS Rate,148.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,279,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,48.58,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,218.1,100,,,Fee Schedule,100% of CMS OPPS Rate,48.58,772.08,
NURSE ONLY VISIT,7429999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
"New patient office or other outpatient visit, typically 10 minutes",7430002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,137.1,
"New patient office or other outpatient visit, typically 30 min",7430003,CDM,510,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,151.92,
Outpatient visit of established patient not requiring a physician,7430006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,105.63,
Outpatient visit of established patient requiring a physician,7430007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,144,
"Established patient office or other outpatient visit, typically 15 minutes",7430008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,137.1,
TRANSFUSION BLOOD OR BLD COMPONENTS,7430024,CDM,391,RC,36430,HCPCS,Outpatient,,,620.1,372.06,,1312.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,370.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,764.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,434.07,70,,,percent of total billed charges,70% of total billed charges,465.08,75,,,percent of total billed charges,75% of total billed charges,667.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,496.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1297.39,350,,,Fee Schedule,350% of CMS OPPS Rate,378.09,103,,,Fee Schedule,103% of CMS OPPS Rate,474.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,106.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,279.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,434.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,372.06,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,434.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,852.57,100,,,Fee Schedule,100% of CMS OPPS Rate,297.65,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,558.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,97.17,1373,
INJECTION SQ OR IM,7430037,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
HYDRATION INFUSION INITIAL HR,7430058,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,7430059,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",7430060,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",7430061,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,7430062,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,7430063,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,,,,,Other,Not Separately reimbursable,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
CHEMO INITIAL IV PUSH OR IVPB <= 15 MIN,7430064,CDM,335,RC,96409,HCPCS,Outpatient,,,257.4,154.44,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.18,70,,,percent of total billed charges,70% of total billed charges,193.05,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,205.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,196.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,115.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,180.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,123.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,231.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,40.33,664.77,
CHEMO NON HORMO ANTINEO INJ SQ OR IM,7430065,CDM,331,RC,96401,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
CHEMO HORMO ANTINEO INJ SQ OR IM,7430066,CDM,331,RC,96402,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
CHEMO IV INITIAL HR >15 MIN <= 1HR,7430067,CDM,335,RC,96413,HCPCS,Outpatient,,,600.77,360.46,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,420.54,70,,,percent of total billed charges,70% of total billed charges,450.58,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,480.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,459.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,270.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,420.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,420.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,288.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,540.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,94.14,1070.43,
Chemotherapy infusion-each additional hour,7430068,CDM,335,RC,96415,HCPCS,Outpatient,,,85,51,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.5,70,,,percent of total billed charges,70% of total billed charges,63.75,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,65.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.65,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,38.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,59.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,40.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,76.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,13.32,400,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",7430069,CDM,940,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,174,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",7430070,CDM,940,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,174,
CHEMO ADDL IVP OR IV <=15 MIN SAME/DIFFR,7430071,CDM,335,RC,96411,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
IRRIG DRUG DELIVERY DEVICE,7430072,CDM,260,RC,96523,HCPCS,Outpatient,,,106.7,64.02,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.69,70,,,percent of total billed charges,70% of total billed charges,80.03,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,81.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,48.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,51.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,96.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.72,334,
Chemotherapy infusion-additional IV pushes of the same medication,7430073,CDM,335,RC,96417,HCPCS,Outpatient,,,294.8,176.88,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.36,70,,,percent of total billed charges,70% of total billed charges,221.1,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,235.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,225.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,132.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,206.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,141.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,265.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,400,
PROLONGED CHEMO ADMIN VIA PORT IMPL PUMP,7430075,CDM,335,RC,96416,HCPCS,Outpatient,,,401.28,240.77,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,280.9,70,,,percent of total billed charges,70% of total billed charges,300.96,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,321.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,306.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.14,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,180.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,280.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,240.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,280.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,192.61,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,361.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.88,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,62.88,1070.43,
REFILL AND MAINT PORTABLE PUMP,7430076,CDM,761,RC,96521,HCPCS,Outpatient,,,393.2,235.92,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,294.9,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,314.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,300.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,67.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,176.94,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,275.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,235.92,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.24,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,188.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,353.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.61,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,61.61,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",7430086,CDM,940,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,174,
NURSE ONLY VISIT PRODUCTIVITY,7431000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
ON-BODY INJECTOR APLCTN FOR TIMED SQ INJ,7436377,CDM,510,RC,96377,HCPCS,Outpatient,,,261,156.6,,136.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.75,75,,,percent of total billed charges,75% of total billed charges,69.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,234.9,
BLOOD DRAW FROM CENTRL OR PERIPHRL CATH,7436592,CDM,761,RC,36592,HCPCS,Outpatient,,,106.7,64.02,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,80.03,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,106.7,103,,,Fee Schedule,103% of CMS OPPS Rate,81.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,48.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,51.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,96.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.72,373.66,
Outpatient visit of established patient not requiring a physician,7440006,CDM,510,RC,99211,HCPCS,Outpatient,,,124,74.4,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,111.6,
Outpatient visit of established patient requiring a physician,7440007,CDM,510,RC,99212,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,137.1,
"Established patient office or other outpatient visit, typically 15 minutes",7440008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,137.1,
"Established patient office or other outpatient, visit typically 40 minutes",7440010,CDM,510,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,,,,,Other,Not Separately reimbursable,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,201.31,
NURSE ONLY VISIT PRODUCTIVITY,7441000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INTRO NDL OR INTRACATH VEIN,7441272,CDM,761,RC,36000,HCPCS,Outpatient,,,90.8,54.48,,,,,,Other,Not Separately reimbursable,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.1,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,72.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.86,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,63.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,54.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.56,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,81.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,14.23,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.23,81.72,
TRANSFUSION BLOOD OR BLD COMPONENTS,7441275,CDM,391,RC,36430,HCPCS,Outpatient,,,652,391.2,,1312.22,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,370.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,764.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,456.4,70,,,percent of total billed charges,70% of total billed charges,489,75,,,percent of total billed charges,75% of total billed charges,667.23,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,521.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1297.39,350,,,Fee Schedule,350% of CMS OPPS Rate,378.09,103,,,Fee Schedule,103% of CMS OPPS Rate,498.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,112.34,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,293.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,456.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,391.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,100,,,Case rate,Pays based on per visit ,456.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,852.57,100,,,Fee Schedule,100% of CMS OPPS Rate,312.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,586.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,102.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,370.68,100,,,Fee Schedule,100% of CMS OPPS Rate,102.17,1373,
PPD TB INTRADERMAL TEST,7441576,CDM,300,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
Immunization administration by a medical assistant or nurse,7441585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7441586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7441587,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
HYDRATION INFUSION INITIAL HR,7441590,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,7441591,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",7441592,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",7441593,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,7441594,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
INJECTION SQ OR IM,7441596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",7441598,CDM,940,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,238.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,174,664.77,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",7441599,CDM,940,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,174,
Allergy shot-1 shot,7441676,CDM,924,RC,95115,HCPCS,Outpatient,,,47.04,28.22,,136.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.93,70,,,percent of total billed charges,70% of total billed charges,35.28,75,,,percent of total billed charges,75% of total billed charges,69.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,35.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,21.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,711,100,,,Case rate,Pays based on per visit ,32.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,22.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.37,711,
CHEMO INITIAL IV PUSH OR IVPB <= 15 MIN,7441690,CDM,335,RC,96409,HCPCS,Outpatient,,,257.4,154.44,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.18,70,,,percent of total billed charges,70% of total billed charges,193.05,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,205.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,196.91,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.35,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,115.83,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,180.18,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,123.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,231.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.33,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,40.33,664.77,
CHEMO ADDL IVP OR IV <=15 MIN SAME/DIFFR,7441691,CDM,335,RC,96411,HCPCS,Outpatient,,,171.9,103.14,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.33,70,,,percent of total billed charges,70% of total billed charges,128.93,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,137.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,131.5,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.62,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,77.36,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,103.14,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,120.33,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.51,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,154.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.94,400,
CHEMO IV INITIAL HR >15 MIN <= 1HR,7441692,CDM,335,RC,96413,HCPCS,Outpatient,,,600.77,360.46,,1070.43,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,302.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,606.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,420.54,70,,,percent of total billed charges,70% of total billed charges,450.58,75,,,percent of total billed charges,75% of total billed charges,544.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,480.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1058.33,350,,,Fee Schedule,350% of CMS OPPS Rate,308.43,103,,,Fee Schedule,103% of CMS OPPS Rate,459.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,103.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,270.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,420.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,360.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,420.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,695.47,100,,,Fee Schedule,100% of CMS OPPS Rate,288.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,540.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,94.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,302.38,100,,,Fee Schedule,100% of CMS OPPS Rate,94.14,1070.43,
Chemotherapy infusion-each additional hour,7441693,CDM,335,RC,96415,HCPCS,Outpatient,,,72.16,43.3,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,50.51,70,,,percent of total billed charges,70% of total billed charges,54.12,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,57.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,55.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,12.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,32.47,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,50.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,43.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,50.51,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,64.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.31,400,
Chemotherapy infusion-additional IV pushes of the same medication,7441694,CDM,335,RC,96417,HCPCS,Outpatient,,,294.8,176.88,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.36,70,,,percent of total billed charges,70% of total billed charges,221.1,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,235.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,225.52,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,132.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,206.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,176.88,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,400,100,,,Case rate,Pays based on per visit ,206.36,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,141.5,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,265.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,46.2,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,46.2,400,
IRRIG DRUG DELIVERY DEVICE,7441803,CDM,260,RC,96523,HCPCS,Outpatient,,,106.7,64.02,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,114.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,74.69,70,,,percent of total billed charges,70% of total billed charges,80.03,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,81.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,48.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,51.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,96.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.72,334,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",7441845,CDM,940,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges,64.13,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,174,100,,,Case rate,Pays based on per visit ,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,174,
Immunization administration by a medical assistant or nurse,7442180,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ON-BODY INJECTOR APLCTN FOR TIMED SQ INJ,7446377,CDM,510,RC,96377,HCPCS,Outpatient,,,261,156.6,,136.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.75,75,,,percent of total billed charges,75% of total billed charges,69.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,208.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,199.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44.97,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,117.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,156.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,125.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,234.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.9,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,234.9,
BLOOD DRAW FROM CENTRL OR PERIPHRL CATH,7446592,CDM,761,RC,36592,HCPCS,Outpatient,,,106.7,64.02,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,80.03,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,85.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,106.7,103,,,Fee Schedule,103% of CMS OPPS Rate,81.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,18.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,48.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,64.02,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.69,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,51.22,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,96.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,16.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.72,373.66,
"New patient office or other outpatient visit, typically 10 minutes",7460002,CDM,510,RC,99202,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,144,
Outpatient visit of established patient not requiring a physician,7460006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,105.63,
Outpatient visit of established patient requiring a physician,7460007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,144,
"Established patient office or other outpatient visit, typically 15 minutes",7460008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,,,,,Other,Not Separately reimbursable,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.83,137.1,
Incision and drainage of abscess; simple or single and complex or multiple,7461022,CDM,761,RC,10060,HCPCS,Outpatient,,,297.44,178.46,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,297.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,223.08,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,581.14,
BIOPSY VAGINAL MUCOSA,7461381,CDM,761,RC,57100,HCPCS,Outpatient,,,867.2,520.32,,2263.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,867.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1173.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,650.4,75,,,percent of total billed charges,75% of total billed charges,1151.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,693.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2238.33,350,,,Fee Schedule,350% of CMS OPPS Rate,652.29,103,,,Fee Schedule,103% of CMS OPPS Rate,663.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,390.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,607.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,607.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1470.9,100,,,Fee Schedule,100% of CMS OPPS Rate,416.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,780.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,390.24,2263.91,
COLPOSCOPY,7461389,CDM,761,RC,57452,HCPCS,Outpatient,,,206.4,123.84,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,154.8,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,165.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,157.9,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,35.56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,92.88,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,144.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.84,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.48,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,99.07,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,185.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,32.34,573.26,
PPD TB INTRADERMAL TEST,7461576,CDM,300,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
Immunization administration by a medical assistant or nurse,7461585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7461586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7461587,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ADMIN VACCINE EA ADDL,7461588,CDM,771,RC,90472,HCPCS,Outpatient,,,40.58,24.35,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.29,50,,,percent of total billed charges,pays at 50% of total billed charges,28.41,70,,,percent of total billed charges,70% of total billed charges,30.44,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,42,
INJECTION SQ OR IM,7461596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
Allergy shot-1 shot,7461676,CDM,924,RC,95115,HCPCS,Outpatient,,,47.04,28.22,,136.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,32.93,70,,,percent of total billed charges,70% of total billed charges,35.28,75,,,percent of total billed charges,75% of total billed charges,69.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,37.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,35.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,21.17,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,32.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,28.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,711,100,,,Case rate,Pays based on per visit ,32.93,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,22.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,7.37,711,
NURSE ONLY VISIT PRODUCTIVITY,7461846,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Immunization administration by a medical assistant or nurse,7462180,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
NURSE ONLY VISIT,7469999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Draining or injecting medication into a small joint/bursa without ultrasound,7480001,CDM,510,RC,20600,HCPCS,Outpatient,,,397,238.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,303.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,875,
Draining or injecting medication into a large joint/bursa without ultrasound,7480002,CDM,510,RC,20605,HCPCS,Outpatient,,,397,238.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,303.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,875,
Draining or injecting medication into a major joint/bursa without ultrasound,7480003,CDM,510,RC,20610,HCPCS,Outpatient,,,397,238.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,303.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,875,
Removal of fluid or injection of medication into a ganglion cyst,7480004,CDM,510,RC,20612,HCPCS,Outpatient,,,397,238.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,397,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,303.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,875,
Injection of medication into a tendon or ligament,7480005,CDM,510,RC,20550,HCPCS,Outpatient,,,397,238.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,303.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,875,
INJECT CARPAL TUNNEL/TARSAL TUNNEL,7480008,CDM,510,RC,20526,HCPCS,Outpatient,,,397,238.2,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.75,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,303.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.4,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.56,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.21,875,
Outpatient visit of established patient not requiring a physician,7480013,CDM,510,RC,99211,HCPCS,Outpatient,,,117,70.2,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.75,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,93.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,105.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,105.3,
Outpatient visit of established patient requiring a physician,7480014,CDM,510,RC,99212,HCPCS,Outpatient,,,152,91.2,,,,,,Other,Not Separately reimbursable,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,75,,,percent of total billed charges,75% of total billed charges,,,,,Other,Not Separately reimbursable,121.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.28,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,136.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.87,136.8,
INJECTION TRIGGER POINT 1 OR 2,7480016,CDM,510,RC,20552,HCPCS,Outpatient,,,318,190.8,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.5,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.64,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.83,875,
Injection of medication into the tendon/ligament origin,7490551,CDM,510,RC,20551,HCPCS,Outpatient,,,397.38,238.43,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.04,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,304,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,68.47,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,278.17,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,190.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,357.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,62.27,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,62.27,875,
Draining or injecting medication into a small joint/bursa without ultrasound,7490600,CDM,510,RC,20600,HCPCS,Outpatient,,,317.9,190.74,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.43,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.81,875,
Draining or injecting medication into a large joint/bursa without ultrasound,7490605,CDM,510,RC,20605,HCPCS,Outpatient,,,317.9,190.74,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.43,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.77,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.74,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.53,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.59,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.81,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.81,875,
Draining or injecting medication into a major joint/bursa without ultrasound,7490610,CDM,510,RC,20610,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,875,
NURSE ONLY VISIT,7491000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INJECTION SQ OR IM,7496372,CDM,510,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,44,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,97.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,40.01,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,40.01,229.82,
CLINIC NEW PT LEVEL 1,7499201,CDM,510,RC,99201,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,117.37,
Outpatient visit of established patient not requiring a physician,7499211,CDM,510,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
Outpatient visit of established patient requiring a physician,7499212,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7499213,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Immunization administration by a medical assistant or nurse,7510471,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ADMIN VACCINE EA ADDL,7510472,CDM,771,RC,90472,HCPCS,Outpatient,,,40.58,24.35,,7.3,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,7.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.29,50,,,percent of total billed charges,pays at 50% of total billed charges,28.41,70,,,percent of total billed charges,70% of total billed charges,30.44,75,,,percent of total billed charges,75% of total billed charges,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,42,
HEARING SCREENING,7512551,CDM,470,RC,92551,HCPCS,Outpatient,,,87.75,52.65,,15.8,18,,,percent of total billed charges,pays at 18% of total charges,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.43,70,,,percent of total billed charges,70% of total billed charges,65.81,75,,,percent of total billed charges,75% of total billed charges,43.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.12,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.65,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,137,100,,,Case rate,Pays based on per visit ,61.43,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.75,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,78.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.75,137,
CIRCUMCISION,7514150,CDM,510,RC,54150,HCPCS,Outpatient,,,99,59.4,,5969.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1686.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.25,75,,,percent of total billed charges,75% of total billed charges,3035.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,79.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5901.95,350,,,Fee Schedule,350% of CMS OPPS Rate,99,103,,,Fee Schedule,103% of CMS OPPS Rate,75.74,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,44.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,59.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,69.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,3878.42,100,,,Fee Schedule,100% of CMS OPPS Rate,47.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,99,100,,,Fee Schedule,100% of CMS OPPS Rate,89.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.27,100,,,Fee Schedule,100% of CMS OPPS Rate,37.62,5969.39,
INJECTION SQ OR IM,7516372,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
Collection of venous blood by venipuncture,7516415,CDM,510,RC,36415,HCPCS,Outpatient,,,12.75,7.65,,30.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,8.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,10.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.99,350,,,Fee Schedule,350% of CMS OPPS Rate,8.74,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,12.75,230,,,Fee Schedule,230% of CMS OPPS Rate,6.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,6.12,30.33,
CLINIC NEW PT LEVEL 1,7519201,CDM,510,RC,99201,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,20.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.39,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.39,117.37,
"New patient office or other outpatient visit, typically 10 minutes",7519202,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"New patient office or other outpatient visit, typically 30 min",7519203,CDM,510,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
Outpatient visit of established patient not requiring a physician,7519211,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7519212,CDM,510,RC,99212,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
"Established patient office or other outpatient visit, typically 15 minutes",7519213,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"New patient office or other outpatient visit, typically 10 minutes",7540002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Outpatient visit of established patient not requiring a physician,7540006,CDM,510,RC,99211,HCPCS,Outpatient,,,124,74.4,,22.32,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.32,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93,75,,,percent of total billed charges,75% of total billed charges,62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,99.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,74.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,47.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,124,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,111.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.32,124,
Outpatient visit of established patient requiring a physician,7540007,CDM,510,RC,99212,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"Established patient office or other outpatient visit, typically 15 minutes",7540008,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",7540009,CDM,510,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
Immunization administration by a medical assistant or nurse,7541585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7541586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7541587,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ADMIN VACCINE EA ADDL,7541588,CDM,771,RC,90472,HCPCS,Outpatient,,,40.58,24.35,,7.3,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,7.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.29,50,,,percent of total billed charges,pays at 50% of total billed charges,28.41,70,,,percent of total billed charges,70% of total billed charges,30.44,75,,,percent of total billed charges,75% of total billed charges,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,42,
INJECTION SQ OR IM,7541596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
Outpatient visit of established patient requiring a physician,7560007,CDM,510,RC,99212,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"Established patient office or other outpatient visit, typically 15 minutes",7560008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Immunization administration by a medical assistant or nurse,7561585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7561586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Outpatient visit of established patient not requiring a physician,7570006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7570007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7570008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
NURSE ONLY VISIT PRODUCTIVITY,7571000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",7571001,CDM,510,RC,11102,HCPCS,Outpatient,,,402.7,241.62,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,581.14,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); each separate/additional lesion",7571002,CDM,510,RC,11103,HCPCS,Outpatient,,,402.7,241.62,,72.49,18,,,percent of total billed charges,pays at 18% of total charges,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,201.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.1,402.7,
"PUNCH BIOPSY, SINGLE",7571003,CDM,510,RC,11104,HCPCS,Outpatient,,,402.7,241.62,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,1200.6,
PUNCH BIOPSY EACH ADDITIONAL,7571004,CDM,510,RC,11105,HCPCS,Outpatient,,,402.7,241.62,,72.49,18,,,percent of total billed charges,pays at 18% of total charges,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,201.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.1,402.7,
SHAVE LESION TRUNK/EXT 0.5CM OR LESS,7571042,CDM,761,RC,11300,HCPCS,Outpatient,,,128.28,76.97,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,96.21,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,128.28,103,,,Fee Schedule,103% of CMS OPPS Rate,98.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,57.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,61.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.28,100,,,Fee Schedule,100% of CMS OPPS Rate,115.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,20.1,1200.61,
SHAVE LESION TRUNK/EXT 0.6 TO 1 CM,7571043,CDM,761,RC,11301,HCPCS,Outpatient,,,155.8,93.48,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.85,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.8,103,,,Fee Schedule,103% of CMS OPPS Rate,119.19,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.84,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,109.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,109.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.78,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.8,100,,,Fee Schedule,100% of CMS OPPS Rate,140.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.41,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.41,581.14,
SHAVE LESION TRUNK/EXT 1.1 TO 2 CM,7571044,CDM,761,RC,11302,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,581.14,
SHAVE LESION TRUNK/EXT OVER 2 CM,7571045,CDM,761,RC,11303,HCPCS,Outpatient,,,319.45,191.67,,1200.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,319.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,239.59,75,,,percent of total billed charges,75% of total billed charges,610.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,255.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.05,350,,,Fee Schedule,350% of CMS OPPS Rate,319.45,103,,,Fee Schedule,103% of CMS OPPS Rate,244.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.04,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,143.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,223.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,191.67,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,121.39,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,223.62,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,153.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,319.45,100,,,Fee Schedule,100% of CMS OPPS Rate,287.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.06,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,50.06,1200.61,
SHAVE LESION<=.5CM SCLP/HND/FEET/GNTL,7571046,CDM,761,RC,11305,HCPCS,Outpatient,,,155.68,93.41,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.76,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.68,103,,,Fee Schedule,103% of CMS OPPS Rate,119.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.68,100,,,Fee Schedule,100% of CMS OPPS Rate,140.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
SHAVE LESION 0.6-1 CM SCLP/HND/FEET/GNTL,7571047,CDM,761,RC,11306,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,581.14,
SHAVE LESION 1.1-2 CM SCLP/HND/FEET/GNTL,7571048,CDM,761,RC,11307,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,581.14,
SHAVE LESION 0.6-1CM FACE,7571051,CDM,761,RC,11311,HCPCS,Outpatient,,,128.28,76.97,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,128.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,96.21,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,102.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,128.28,103,,,Fee Schedule,103% of CMS OPPS Rate,98.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.1,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,57.73,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,76.97,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,89.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,61.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,128.28,100,,,Fee Schedule,100% of CMS OPPS Rate,115.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,20.1,581.14,
EXC TRK ARM LEG<=0.5CM BENIGN,7571053,CDM,761,RC,11400,HCPCS,Outpatient,,,585.6,351.36,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,585.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,439.2,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,468.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,585.6,103,,,Fee Schedule,103% of CMS OPPS Rate,447.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,263.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,281.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.6,100,,,Fee Schedule,100% of CMS OPPS Rate,527.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.53,2088.52,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,7571054,CDM,761,RC,11401,HCPCS,Outpatient,,,782.95,469.77,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,782.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,587.21,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,626.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,598.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,352.33,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,548.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,469.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,297.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,548.07,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,375.82,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,704.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,782.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,297.52,1200.6,
EXC TRK ARM LG 1.1-2 CM BENIGN,7571055,CDM,761,RC,11402,HCPCS,Outpatient,,,585.6,351.36,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,585.6,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,439.2,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,468.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,585.6,103,,,Fee Schedule,103% of CMS OPPS Rate,447.98,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,263.52,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351.36,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.53,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.92,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,281.09,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.6,100,,,Fee Schedule,100% of CMS OPPS Rate,527.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.53,2088.52,
EXC TRK ARM LG 2.1-3CM BENIGN,7571056,CDM,761,RC,11403,HCPCS,Outpatient,,,1016.04,609.62,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1016.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,762.03,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,777.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,457.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,487.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,914.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,2088.52,
EXC TRK ARM LG 3.1-4CM BENIGN,7571057,CDM,761,RC,11404,HCPCS,Outpatient,,,1952.88,1171.73,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1952.88,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2088.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1464.66,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1562.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1493.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,878.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1367.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1171.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,742.09,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1367.02,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,937.38,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1757.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1952.88,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,742.09,4825.85,
EXC BENIGN LESION 0.6 TO 1 CM,7571060,CDM,761,RC,11421,HCPCS,Outpatient,,,1016.04,609.62,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1016.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,762.03,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,777.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,457.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,487.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,914.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,2088.52,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,7571061,CDM,761,RC,11422,HCPCS,Outpatient,,,1016.04,609.62,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1016.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1016.04,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2336.23,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,762.03,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1016.04,103,,,Fee Schedule,103% of CMS OPPS Rate,777.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,457.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,487.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of CMS OPPS Rate,914.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,4825.85,
EXC BENIGN  LSN FACE 0.6 TO 1 CM,7571066,CDM,761,RC,11441,HCPCS,Outpatient,,,585.64,351.38,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,585.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,439.23,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,468.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,585.64,103,,,Fee Schedule,103% of CMS OPPS Rate,448.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,263.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,281.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of CMS OPPS Rate,527.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,2088.52,
EXC TRK ARM LEG <=0.5CM MALIG,7571071,CDM,761,RC,11600,HCPCS,Outpatient,,,1016.04,609.62,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,762.03,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,777.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,175.06,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,457.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,487.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,914.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,159.21,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,159.21,2088.52,
EXC TRK ARM LEG 0.6-1CM MALIG,7571072,CDM,761,RC,11601,HCPCS,Outpatient,,,585.64,351.38,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,585.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,585.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,439.23,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,468.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,585.64,103,,,Fee Schedule,103% of CMS OPPS Rate,448.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,263.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,281.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of CMS OPPS Rate,527.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,2088.52,
Excision-Malignant Lesions,7571073,CDM,761,RC,11602,HCPCS,Outpatient,,,585.64,351.38,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,585.64,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,439.23,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,468.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,448.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,263.54,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,409.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,351.38,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,409.95,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,281.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,527.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,585.64,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,222.54,1200.6,
EXC TRK ARM LEG 2.1-3CM MALIG,7571074,CDM,761,RC,11603,HCPCS,Outpatient,,,1016.04,609.62,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1016.04,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,762.03,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,812.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,777.27,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,457.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,609.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,711.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,487.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,914.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1016.04,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,386.1,2088.52,
EXC TRK ARM LEG 3.1-4 CM MALGNT,7571075,CDM,761,RC,11604,HCPCS,Outpatient,,,1389.05,833.43,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1389.05,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1041.79,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1111.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1062.62,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,625.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,972.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,833.43,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,527.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,972.34,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,666.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1250.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1389.05,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,527.84,2088.52,
EXC TRK ARM LEG OVER 4.0 CM MALGNT,7571076,CDM,761,RC,11606,HCPCS,Outpatient,,,2484.48,1490.69,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2484.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2088.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1863.36,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1987.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1900.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.02,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1739.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1490.69,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,944.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1739.14,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1192.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2236.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2484.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,944.1,4825.85,
EXC LSN SCLP/HND/FET/GNTL 2.1-3.0CM MLGT,7571078,CDM,761,RC,11623,HCPCS,Outpatient,,,4311,2586.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1841.49,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,3233.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3297.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,742.79,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1939.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3017.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2586.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1638.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3017.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2069.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3879.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,675.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,675.53,4825.85,
EXC LSN SCL//HND/FET/GNTL 3.1-4.0 CM ML,7571079,CDM,510,RC,11624,HCPCS,Outpatient,,,4311,2586.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,4311,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3233.25,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3448.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3297.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1939.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3017.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2586.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1638.18,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,3017.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2069.28,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3879.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,4311,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,4825.85,
EXC LSN SCLP/HND/FET/GNTL 0.6-1.0CM MLGT,7571084,CDM,510,RC,11621,HCPCS,Outpatient,,,1907,1144.2,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.25,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1525.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1458.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,328.58,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,858.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1334.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1144.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,724.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1334.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,915.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1716.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,298.83,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,298.83,2088.52,
Destruction of pre-cancerous lesion,7571133,CDM,761,RC,17000,HCPCS,Outpatient,,,155.68,93.41,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.68,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.76,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.68,103,,,Fee Schedule,103% of CMS OPPS Rate,119.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.82,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.41,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.98,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.68,100,,,Fee Schedule,100% of CMS OPPS Rate,140.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
Destruction of 2-14 pre-cancerous lesions,7571134,CDM,761,RC,17003,HCPCS,Outpatient,,,49.44,29.66,,8.9,18,,,percent of total billed charges,pays at 18% of total charges,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.9,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.08,75,,,percent of total billed charges,75% of total billed charges,24.72,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,39.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,37.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,8.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,34.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,29.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,18.79,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,34.61,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.73,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,49.44,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,44.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.75,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.75,49.44,
DESTRUCTION PREMALIGNANT LESION 15/>,7571136,CDM,761,RC,17004,HCPCS,Outpatient,,,687.25,412.35,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,633.69,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,515.44,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,549.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,525.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.41,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,309.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,481.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,412.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,261.16,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,481.08,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,329.88,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,618.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.69,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,107.69,1200.6,
"Removal of skin tags, multiple fibrocutaneous tags, any area",7571200,CDM,761,RC,11200,HCPCS,Outpatient,,,181.48,108.89,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,136.11,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,145.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,138.83,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.27,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,81.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,68.96,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,127.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,87.11,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,163.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,28.44,581.14,
REMOVAL SKIN TAGS EA ADDTL 10 LSNS,7571201,CDM,761,RC,11201,HCPCS,Outpatient,,,45,27,,8.1,18,,,percent of total billed charges,pays at 18% of total charges,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,8.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.75,75,,,percent of total billed charges,75% of total billed charges,22.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,34.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,7.75,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,17.1,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,31.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,45,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,40.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,7.05,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.05,45,
INJECTION SQ OR IM,7571596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
"New patient office or other outpatient visit, typically 10 minutes",7580002,CDM,510,RC,99202,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"New patient office or other outpatient visit, typically 30 min",7580003,CDM,510,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
"New patient office of other outpatient visit, typically 45 min",7580004,CDM,510,RC,99204,HCPCS,Outpatient,,,389,233.4,,70.02,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,70.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.75,75,,,percent of total billed charges,75% of total billed charges,194.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,311.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,297.59,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,233.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,272.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,389,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,350.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,389,
"New patient office of other outpatient visit, typically 60 min",7580005,CDM,510,RC,99205,HCPCS,Outpatient,,,306.04,183.62,,55.09,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,55.09,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.53,75,,,percent of total billed charges,75% of total billed charges,153.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,244.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,234.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,183.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.3,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,214.23,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.9,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,306.04,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,275.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.09,306.04,
Outpatient visit of established patient not requiring a physician,7580011,CDM,510,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
Outpatient visit of established patient requiring a physician,7580012,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7580013,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",7580014,CDM,510,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
"Established patient office or other outpatient, visit typically 40 minutes",7580015,CDM,510,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,40.26,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,111.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.26,223.68,
"New patient office or other outpatient visit, typically 10 minutes",7610002,CDM,510,RC,99202,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"New patient office or other outpatient visit, typically 30 min",7610003,CDM,510,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
Outpatient visit of established patient not requiring a physician,7610006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7610007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7610008,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",7610009,CDM,510,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
"Established patient office or other outpatient, visit typically 40 minutes",7610010,CDM,510,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,40.26,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,111.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.26,223.68,
Initial new patient preventive medicine evaluation (18?9 years),7610011,CDM,510,RC,99385,HCPCS,Outpatient,,,388,232.8,,69.84,18,,,percent of total billed charges,pays at 18% of total charges,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.84,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291,75,,,percent of total billed charges,75% of total billed charges,194,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,310.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,296.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.85,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.6,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.44,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,271.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,388,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,349.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.8,388,
Initial new patient preventive medicine evaluation (40?4 years),7610012,CDM,510,RC,99386,HCPCS,Outpatient,,,470,282,,84.6,18,,,percent of total billed charges,pays at 18% of total charges,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,84.6,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.5,75,,,percent of total billed charges,75% of total billed charges,235,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,376,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,359.55,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,80.98,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,329,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,282,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,178.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,329,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,470,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,423,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,73.65,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.65,470,
Initial visit for new patients 65 and older years old,7610013,CDM,510,RC,99387,HCPCS,Outpatient,,,507,304.2,,91.26,18,,,percent of total billed charges,pays at 18% of total charges,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,91.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.25,75,,,percent of total billed charges,75% of total billed charges,253.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,405.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,387.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,87.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,304.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,354.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.36,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,507,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,456.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,79.45,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.45,507,
Established patient periodic preventive medicine examination age 18-39 years,7610014,CDM,510,RC,99395,HCPCS,Outpatient,,,325,195,,58.5,18,,,percent of total billed charges,pays at 18% of total charges,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,58.5,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.75,75,,,percent of total billed charges,75% of total billed charges,162.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,260,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,195,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,248.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,227.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,195,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.5,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,227.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,325,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,292.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.93,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.93,325,
Established patient periodic preventive medicine examination age 40-64 years,7610015,CDM,510,RC,99396,HCPCS,Outpatient,,,384,230.4,,69.12,18,,,percent of total billed charges,pays at 18% of total charges,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.12,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288,75,,,percent of total billed charges,75% of total billed charges,192,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,307.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,230.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,293.76,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.16,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,230.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,145.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,268.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,384,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,345.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.17,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.17,384,
Periodic primary re-evaluation for an established patient 65 and older,7610016,CDM,510,RC,99397,HCPCS,Outpatient,,,404,242.4,,72.72,18,,,percent of total billed charges,pays at 18% of total charges,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.72,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303,75,,,percent of total billed charges,75% of total billed charges,202,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,323.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,242.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,309.06,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.61,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,242.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,282.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.92,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,404,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,363.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.31,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.31,404,
INITIAL PREV PHYSICAL EXAM 1X MEDICARE|MEDICARE,7610017,CDM,510,RC,G0402,HCPCS,Outpatient,,,264,158.4,,388.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,109.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,75,,,percent of total billed charges,75% of total billed charges,197.76,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,211.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,384.55,350,,,Fee Schedule,350% of CMS OPPS Rate,112.06,103,,,Fee Schedule,103% of CMS OPPS Rate,201.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,45.49,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,118.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,184.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,100.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,184.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,252.7,100,,,Fee Schedule,100% of CMS OPPS Rate,126.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,237.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,41.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,109.87,100,,,Fee Schedule,100% of CMS OPPS Rate,41.37,388.94,
FIRST ANNUAL WELLNESS VISIT- MEDICARE|MEDICARE,7610018,CDM,510,RC,G0438,HCPCS,Outpatient,,,324,194.4,,560.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,158.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243,75,,,percent of total billed charges,75% of total billed charges,284.96,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,259.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,554.09,350,,,Fee Schedule,350% of CMS OPPS Rate,161.48,102,,,Fee Schedule,102% of CMS OPPS Rate,247.86,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,55.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,145.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,226.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,194.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,123.12,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,226.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,364.11,230,,,Fee Schedule,230% of CMS OPPS Rate,155.52,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,291.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,50.77,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,158.31,100,,,Fee Schedule,100% of CMS OPPS Rate,50.77,560.42,
SUBSEQUENT ANNUAL WELLNESS VISIT- MCARE,7610019,CDM,510,RC,G0439,HCPCS,Outpatient,,,252,151.2,,435.92,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189,75,,,percent of total billed charges,75% of total billed charges,221.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.99,350,,,Fee Schedule,350% of CMS OPPS Rate,125.6,102,,,Fee Schedule,102% of CMS OPPS Rate,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,43.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,95.76,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,283.22,230,,,Fee Schedule,230% of CMS OPPS Rate,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,39.49,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,39.49,435.92,
CGM STARTUP AND TRAINING,7610249,CDM,510,RC,95249,HCPCS,Outpatient,,,171,102.6,,184.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.25,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.29,103,,,Fee Schedule,103% of CMS OPPS Rate,130.82,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.46,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,76.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,64.98,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,82.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,153.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.8,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,26.8,184.97,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",7611001,CDM,510,RC,11102,HCPCS,Outpatient,,,402.7,241.62,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,581.14,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); each separate/additional lesion",7611002,CDM,510,RC,11103,HCPCS,Outpatient,,,402.7,241.62,,72.49,18,,,percent of total billed charges,pays at 18% of total charges,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,201.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.1,402.7,
"PUNCH BIOPSY, SINGLE",7611003,CDM,510,RC,11104,HCPCS,Outpatient,,,402.7,241.62,,1200.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,339.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,610.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1187.04,350,,,Fee Schedule,350% of CMS OPPS Rate,345.94,103,,,Fee Schedule,103% of CMS OPPS Rate,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,780.06,100,,,Fee Schedule,100% of CMS OPPS Rate,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,339.15,100,,,Fee Schedule,100% of CMS OPPS Rate,63.1,1200.6,
PUNCH BIOPSY EACH ADDITIONAL,7611004,CDM,510,RC,11105,HCPCS,Outpatient,,,402.7,241.62,,72.49,18,,,percent of total billed charges,pays at 18% of total charges,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,72.49,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.03,75,,,percent of total billed charges,75% of total billed charges,201.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,322.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,308.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.62,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,153.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,281.89,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.3,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,402.7,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,362.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.1,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.1,402.7,
"INCISIONAL BIOPSY, SINGLE",7611005,CDM,510,RC,11106,HCPCS,Outpatient,,,716.8,430.08,,1869.61,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,528.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,75,,,percent of total billed charges,75% of total billed charges,950.65,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,573.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1848.49,350,,,Fee Schedule,350% of CMS OPPS Rate,538.69,103,,,Fee Schedule,103% of CMS OPPS Rate,548.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,272.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.72,100,,,Fee Schedule,100% of CMS OPPS Rate,344.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,645.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,528.14,100,,,Fee Schedule,100% of CMS OPPS Rate,112.32,1869.61,
INCISIONAL BIOPSY EACH ADDITIONAL,7611006,CDM,510,RC,11107,HCPCS,Outpatient,,,716.8,430.08,,129.02,18,,,percent of total billed charges,pays at 18% of total charges,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,129.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,537.6,75,,,percent of total billed charges,75% of total billed charges,358.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,573.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,548.35,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,123.5,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.56,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,430.08,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,272.38,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,501.76,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.06,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,716.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,645.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,112.32,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.32,716.8,
Incision and drainage of abscess; simple or single and complex or multiple,7611022,CDM,761,RC,10060,HCPCS,Outpatient,,,297.44,178.46,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,297.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,223.08,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.03,581.14,
EKG PANEL,7611100,CDM,510,RC,93005,HCPCS,Outpatient,,,402.93,241.76,,184.98,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,52.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.2,75,,,percent of total billed charges,75% of total billed charges,94.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,322.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.89,350,,,Fee Schedule,350% of CMS OPPS Rate,53.3,103,,,Fee Schedule,103% of CMS OPPS Rate,308.24,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,69.42,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,181.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,241.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,153.11,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,282.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,100,,,Fee Schedule,100% of CMS OPPS Rate,193.41,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,362.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,63.14,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,100,,,Fee Schedule,100% of CMS OPPS Rate,52.25,362.64,
PPD TB INTRADERMAL TEST,7611576,CDM,300,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
Immunization administration by a medical assistant or nurse,7611585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7611586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7611587,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ADMIN VACCINE EA ADDL,7611588,CDM,771,RC,90472,HCPCS,Outpatient,,,40.58,24.35,,7.3,18,,,percent of total billed charges,pays at 18% of total charges,,,,,Other,Not Separately reimbursable,7.3,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,20.29,50,,,percent of total billed charges,pays at 50% of total billed charges,28.41,70,,,percent of total billed charges,70% of total billed charges,30.44,75,,,percent of total billed charges,75% of total billed charges,20.29,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.04,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,42,100,,,Case rate,Pays based on per visit ,28.41,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,35.92,100,,,Case rate,pays based on per visit rate,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.3,42,
INJECTION SQ OR IM,7611596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
NURSE ONLY VISIT,7619999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
"New patient office or other outpatient visit, typically 10 minutes",7630002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Outpatient visit of established patient not requiring a physician,7630006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7630007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7630008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"Established patient office or other outpatient visit, typically 25 minutes",7630009,CDM,510,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
INJ TRIGGER PNTS 1-2 MUSCLES,7631200,CDM,761,RC,20552,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,875,
Draining or injecting medication into a large joint/bursa without ultrasound,7631203,CDM,761,RC,20605,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,875,
Draining or injecting medication into a major joint/bursa without ultrasound,7631204,CDM,761,RC,20610,HCPCS,Outpatient,,,317.92,190.75,,875,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,247.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,498.92,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,238.44,75,,,percent of total billed charges,75% of total billed charges,444.91,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,254.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,865.1,350,,,Fee Schedule,350% of CMS OPPS Rate,252.11,103,,,Fee Schedule,103% of CMS OPPS Rate,243.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,54.78,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,143.06,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,190.75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,120.81,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,222.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,100,,,Fee Schedule,100% of CMS OPPS Rate,152.6,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,286.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,49.82,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,247.17,100,,,Fee Schedule,100% of CMS OPPS Rate,49.82,875,
PPD TB INTRADERMAL TEST,7631576,CDM,300,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
Immunization administration by a medical assistant or nurse,7631586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",7631592,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",7631593,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
INJECTION SQ OR IM,7631596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
ASTHMA EDUCATION 30 MIN TEACHING,7631597,CDM,410,RC,98960,HCPCS,Outpatient,,,87.84,52.7,,15.81,18,,,percent of total billed charges,pays at 18% of total charges,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.81,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,51.89,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.49,70,,,percent of total billed charges,70% of total billed charges,65.88,75,,,percent of total billed charges,75% of total billed charges,43.92,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,70.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,52.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,67.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,15.13,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,61.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,52.7,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,313,100,,,Case rate,Pays based on per visit ,61.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,87.84,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,79.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.76,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.76,313,
"New patient office or other outpatient visit, typically 10 minutes",7760002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"New patient office or other outpatient visit, typically 30 min",7760003,CDM,510,RC,99203,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
Outpatient visit of established patient not requiring a physician,7760006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7760007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7760008,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 25 minutes",7760009,CDM,510,RC,99214,HCPCS,Outpatient,,,168.8,101.28,,30.38,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,30.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.6,75,,,percent of total billed charges,75% of total billed charges,84.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,135.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,129.13,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,101.28,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,64.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,118.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,168.8,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,151.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,168.8,
"Established patient office or other outpatient, visit typically 40 minutes",7760010,CDM,510,RC,99215,HCPCS,Outpatient,,,223.68,134.21,,40.26,18,,,percent of total billed charges,pays at 18% of total charges,56.77,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,40.26,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.76,75,,,percent of total billed charges,75% of total billed charges,111.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,178.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,171.12,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.66,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,134.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,85,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,156.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,223.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,201.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,56.77,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.26,223.68,
NURSE ONLY VISIT PRODUCTIVITY,7761000,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Incision and drainage of abscess; simple or single and complex or multiple,7761022,CDM,761,RC,10060,HCPCS,Outpatient,,,297.44,178.46,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,297.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,223.08,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,237.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,227.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,133.85,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,178.46,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,208.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.57,100,,,Fee Schedule,100% of CMS OPPS Rate,142.77,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,267.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,297.44,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,113.03,581.14,
Destruction of 1-14 common or plantar warts,7761139,CDM,761,RC,17110,HCPCS,Outpatient,,,155.7,93.42,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,155.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,116.78,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,124.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,155.7,103,,,Fee Schedule,103% of CMS OPPS Rate,119.11,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,26.83,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,70.07,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,108.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,93.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,59.17,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,108.99,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,74.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,155.7,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,24.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,24.4,581.14,
Chemical destruction of pre-cancerous lesions of the skin,7761141,CDM,761,RC,17250,HCPCS,Outpatient,,,170.19,102.11,,581.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,164.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,344.47,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,127.64,75,,,percent of total billed charges,75% of total billed charges,295.49,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,136.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,574.57,350,,,Fee Schedule,350% of CMS OPPS Rate,167.44,103,,,Fee Schedule,103% of CMS OPPS Rate,130.2,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,29.32,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,76.59,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,119.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,102.11,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,64.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,119.13,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,377.58,100,,,Fee Schedule,100% of CMS OPPS Rate,81.69,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,153.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,26.67,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,164.16,100,,,Fee Schedule,100% of CMS OPPS Rate,26.67,581.14,
INCISION & DRNG BREAST ABSCESS DEEP,7761189,CDM,761,RC,19020,HCPCS,Outpatient,,,2296.48,1377.89,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,2296.48,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2583.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,1722.36,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1837.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,1756.81,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1033.42,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1607.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1377.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,872.66,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,1607.54,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.31,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,2066.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,2296.48,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,872.66,4825.85,
INSERTION OF STRGHT BLADDER CATH,7761340,CDM,761,RC,51701,HCPCS,Outpatient,,,212.93,127.76,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,159.7,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,170.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,162.89,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.69,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,95.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,80.91,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,149.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,102.21,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,191.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.37,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,33.37,373.66,
INSERTION OF INDWELLING BLADDER CATH,7761341,CDM,761,RC,51702,HCPCS,Outpatient,,,130.7,78.42,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,98.03,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,104.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,99.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,22.52,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,58.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,91.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,49.67,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,91.49,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,62.74,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,117.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,20.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,20.48,373.66,
INCSN AND DRNG BARTHOLIN'S GLAND ABSCESS,7761372,CDM,761,RC,56420,HCPCS,Outpatient,,,277.95,166.77,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,277.95,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,208.46,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,222.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,212.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,125.08,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,194.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,166.77,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,105.62,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,194.57,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,133.42,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,250.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,277.95,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,105.62,573.26,
BIOPSY LESION VULVA OR PERINEUM,7761374,CDM,761,RC,56605,HCPCS,Outpatient,,,534,320.4,,2263.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,534,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,534,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1173.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,400.5,75,,,percent of total billed charges,75% of total billed charges,1151.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,427.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2238.33,350,,,Fee Schedule,350% of CMS OPPS Rate,534,103,,,Fee Schedule,103% of CMS OPPS Rate,408.51,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,240.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,373.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,320.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,202.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,373.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1470.9,100,,,Fee Schedule,100% of CMS OPPS Rate,256.32,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,534,100,,,Fee Schedule,100% of CMS OPPS Rate,480.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,534,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,202.92,2263.91,
BIOPSY PERINEUM EA ADDTL,7761375,CDM,761,RC,56606,HCPCS,Outpatient,,,258,154.8,,46.44,18,,,percent of total billed charges,pays at 18% of total charges,258,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,46.44,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.5,75,,,percent of total billed charges,75% of total billed charges,129,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,206.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,154.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,197.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,180.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,154.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,98.04,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,180.6,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.84,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,258,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,232.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,258,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.44,258,
INSERT DRUG DELIVERY IMPLANT,7761380,CDM,761,RC,11981,HCPCS,Outpatient,,,112,67.2,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,214.17,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,84,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,89.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,85.68,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.3,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,50.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,42.56,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,78.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,53.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,100.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.55,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,17.55,373.66,
BIOPSY VAGINAL MUCOSA,7761381,CDM,761,RC,57100,HCPCS,Outpatient,,,867.2,520.32,,2263.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,867.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1173.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,650.4,75,,,percent of total billed charges,75% of total billed charges,1151.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,693.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2238.33,350,,,Fee Schedule,350% of CMS OPPS Rate,652.29,103,,,Fee Schedule,103% of CMS OPPS Rate,663.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,390.24,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,607.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.32,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,329.54,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,607.04,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1470.9,100,,,Fee Schedule,100% of CMS OPPS Rate,416.26,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,780.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.2,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,329.54,2263.91,
REMOVE DRUG DELIVERY IMPLANT,7761382,CDM,761,RC,11982,HCPCS,Outpatient,,,115.36,69.22,,1215.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,115.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,672.86,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,86.52,75,,,percent of total billed charges,75% of total billed charges,617.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1201.37,350,,,Fee Schedule,350% of CMS OPPS Rate,115.36,103,,,Fee Schedule,103% of CMS OPPS Rate,88.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,51.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,43.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,789.47,100,,,Fee Schedule,100% of CMS OPPS Rate,55.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,103.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.08,1215.1,
REMOVAL W REINSERT DRUG DELIVERY IMPLANT,7761383,CDM,761,RC,11983,HCPCS,Outpatient,,,115.36,69.22,,1215.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,115.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,672.86,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,86.52,75,,,percent of total billed charges,75% of total billed charges,617.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,92.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1201.37,350,,,Fee Schedule,350% of CMS OPPS Rate,115.36,103,,,Fee Schedule,103% of CMS OPPS Rate,88.25,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,19.88,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,51.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,80.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69.22,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,43.84,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,80.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,789.47,100,,,Fee Schedule,100% of CMS OPPS Rate,55.37,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,115.36,100,,,Fee Schedule,100% of CMS OPPS Rate,103.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,18.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,343.24,100,,,Fee Schedule,100% of CMS OPPS Rate,18.08,1215.1,
INSERT PESSARY OBGYN,7761384,CDM,761,RC,57160,HCPCS,Outpatient,,,217,130.2,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,162.75,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,166.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,97.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,104.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,195.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,34,573.26,
ANOSCOPY,7761385,CDM,510,RC,46600,HCPCS,Outpatient,,,218.78,131.27,,373.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,218.78,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,105.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.09,75,,,percent of total billed charges,75% of total billed charges,190,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,175.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,369.44,350,,,Fee Schedule,350% of CMS OPPS Rate,107.66,103,,,Fee Schedule,103% of CMS OPPS Rate,167.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,98.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,153.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,131.27,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,83.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,153.15,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,242.77,100,,,Fee Schedule,100% of CMS OPPS Rate,105.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,196.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,218.78,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,105.55,100,,,Fee Schedule,100% of CMS OPPS Rate,83.14,373.66,
COLPOSCOPY,7761389,CDM,761,RC,57452,HCPCS,Outpatient,,,217,130.2,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,162.75,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,166.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,97.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,104.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,195.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,34,573.26,
Biopsy of cervix or uterus,7761390,CDM,761,RC,57454,HCPCS,Outpatient,,,423,253.8,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,423,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,547.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,317.25,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,338.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,270.72,103,,,Fee Schedule,103% of CMS OPPS Rate,323.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,190.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,253.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,160.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,296.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,203.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,380.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,423,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,160.74,939.58,
COLPOSCOPY CERVIX W BIOPSY,7761391,CDM,761,RC,57455,HCPCS,Outpatient,,,397.29,238.37,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,397.29,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,547.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,297.97,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,317.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,270.72,103,,,Fee Schedule,103% of CMS OPPS Rate,303.93,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,178.78,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,278.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,238.37,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,150.97,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,278.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,190.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,357.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,397.29,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,150.97,939.58,
COLPOSCOPY CERVIX W CURETTAGE,7761392,CDM,761,RC,57456,HCPCS,Outpatient,,,202.99,121.79,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,202.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,547.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,152.24,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,162.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,202.99,103,,,Fee Schedule,103% of CMS OPPS Rate,155.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,91.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,142.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,121.79,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,77.14,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,142.09,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,97.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,202.99,100,,,Fee Schedule,100% of CMS OPPS Rate,182.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,202.99,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,77.14,939.58,
BIOPSY CERVIX OR LOCAL EXC LSN,7761395,CDM,761,RC,57500,HCPCS,Outpatient,,,867.16,520.3,,2263.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,867.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1173.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,650.37,75,,,percent of total billed charges,75% of total billed charges,1151.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,693.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2238.33,350,,,Fee Schedule,350% of CMS OPPS Rate,652.29,103,,,Fee Schedule,103% of CMS OPPS Rate,663.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,390.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,607.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,329.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,607.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1470.9,100,,,Fee Schedule,100% of CMS OPPS Rate,416.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,780.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,329.52,2263.91,
ENDOCERVICAL CURRETAGE,7761396,CDM,761,RC,57505,HCPCS,Outpatient,,,867.16,520.3,,2263.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,867.16,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,639.52,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1173.59,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,650.37,75,,,percent of total billed charges,75% of total billed charges,1151.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,693.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2238.33,350,,,Fee Schedule,350% of CMS OPPS Rate,652.29,103,,,Fee Schedule,103% of CMS OPPS Rate,663.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,390.22,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,607.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,520.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,329.52,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,607.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,1470.9,100,,,Fee Schedule,100% of CMS OPPS Rate,416.24,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,780.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,867.16,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,639.52,100,,,Fee Schedule,100% of CMS OPPS Rate,329.52,2263.91,
CAUTERY CERVIX CRYOCAUTERY,7761398,CDM,761,RC,57511,HCPCS,Outpatient,,,212.59,127.55,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,212.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,547.14,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,159.44,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,170.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,212.59,103,,,Fee Schedule,103% of CMS OPPS Rate,162.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,95.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,148.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,148.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,102.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.59,100,,,Fee Schedule,100% of CMS OPPS Rate,191.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,265.41,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,939.58,
Biopsy of the lining of the uterus,7761402,CDM,761,RC,58100,HCPCS,Outpatient,,,217,130.2,,573.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,161.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,162.75,75,,,percent of total billed charges,75% of total billed charges,291.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,173.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.77,350,,,Fee Schedule,350% of CMS OPPS Rate,165.17,103,,,Fee Schedule,103% of CMS OPPS Rate,166.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.39,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,97.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,82.46,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,151.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,372.44,100,,,Fee Schedule,100% of CMS OPPS Rate,104.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,195.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,161.93,100,,,Fee Schedule,100% of CMS OPPS Rate,34,573.26,
INSERT IUD,7761404,CDM,761,RC,58300,HCPCS,Outpatient,,,240,144,,43.2,18,,,percent of total billed charges,pays at 18% of total charges,240,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,43.2,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,111.85,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,180,75,,,percent of total billed charges,75% of total billed charges,120,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,192,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,183.6,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,91.2,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,168,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,240,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,216,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,240,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,240,
REMOVE IUD,7761405,CDM,761,RC,58301,HCPCS,Outpatient,,,212.59,127.55,,939.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,212.59,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,265.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,327.65,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,,,,,Other,Not Separately reimbursable,159.44,75,,,percent of total billed charges,75% of total billed charges,477.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,170.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,928.97,350,,,Fee Schedule,350% of CMS OPPS Rate,212.59,103,,,Fee Schedule,103% of CMS OPPS Rate,162.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,95.67,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,148.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.55,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,148.81,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,610.46,100,,,Fee Schedule,100% of CMS OPPS Rate,102.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,212.59,100,,,Fee Schedule,100% of CMS OPPS Rate,191.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,212.59,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,265.42,100,,,Fee Schedule,100% of CMS OPPS Rate,80.78,939.58,
PPD TB INTRADERMAL TEST,7761576,CDM,300,RC,86580,HCPCS,Outpatient,,,62,37.2,,80.32,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,6.31,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,22.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,35.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges,46.5,75,,,percent of total billed charges,75% of total billed charges,40.84,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,49.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,79.41,350,,,Fee Schedule,350% of CMS OPPS Rate,23.14,103,,,Fee Schedule,103% of CMS OPPS Rate,47.43,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,27.9,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,15.72,100,,,Fee Schedule,100% of UHC Fee Schedule,43.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,100,,,Fee Schedule,100% of CMS OPPS Rate,29.76,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,6.31,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,22.69,100,,,Fee Schedule,100% of CMS OPPS Rate,6.31,80.32,
INJECTION SQ OR IM,7761596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
Outpatient visit of established patient not requiring a physician,7800006,CDM,510,RC,99211,HCPCS,Outpatient,,,117.37,70.42,,21.13,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,21.13,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.03,75,,,percent of total billed charges,75% of total billed charges,58.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,93.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,89.79,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.82,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,70.42,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,44.6,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,82.16,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.34,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,117.37,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,105.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,117.37,
Outpatient visit of established patient requiring a physician,7800007,CDM,510,RC,99212,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
"Established patient office or other outpatient visit, typically 15 minutes",7800008,CDM,510,RC,99213,HCPCS,Outpatient,,,160,96,,28.8,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,28.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,75,,,percent of total billed charges,75% of total billed charges,80,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,128,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,122.4,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,96,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,60.8,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,112,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,160,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,144,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.8,160,
Immunization administration by a medical assistant or nurse,7801585,CDM,510,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.26,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,62.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.7,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,25.7,217.13,
"New patient office or other outpatient visit, typically 10 minutes",7810002,CDM,510,RC,99202,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Outpatient visit of established patient not requiring a physician,7810006,CDM,510,RC,99211,HCPCS,Outpatient,,,123,73.8,,22.14,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,22.14,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.25,75,,,percent of total billed charges,75% of total billed charges,61.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,98.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,94.1,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,46.74,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,86.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,123,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,110.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,123,
Outpatient visit of established patient requiring a physician,7810007,CDM,510,RC,99212,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,32.87,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,32.87,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
"Established patient office or other outpatient visit, typically 15 minutes",7810008,CDM,510,RC,99213,HCPCS,Outpatient,,,152.33,91.4,,27.42,18,,,percent of total billed charges,pays at 18% of total charges,37.83,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,27.42,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.25,75,,,percent of total billed charges,75% of total billed charges,76.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,121.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,116.53,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,91.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,57.89,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,106.63,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.12,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,152.33,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,137.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,37.83,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.42,152.33,
Immunization administration by a medical assistant or nurse,7811585,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
Immunization administration by a medical assistant or nurse,7811586,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
INJECTION SQ OR IM,7811596,CDM,940,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,174,100,,,Case rate,Pays based on per visit ,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,229.82,
NURSE ONLY VISIT,7819999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
OBSERVATION ROOM PER 1 HR 9T MICU,9030003O,CDM,762,RC,G0378,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,2247,
9T MEDICAL ICU OBSERVATION HR,9030007,CDM,762,RC,G0378,HCPCS,Outpatient,,,33.68,20.21,,6.06,18,,,percent of total billed charges,pays at 18% of total charges,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,6.06,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,23.58,70,,,percent of total billed charges,70% of total billed charges,25.26,75,,,percent of total billed charges,75% of total billed charges,16.84,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,26.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,25.77,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,5.8,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.16,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2247,100,,,Case rate,Pays based on per visit ,23.58,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2239,100,,,Case rate,pays based on per visit rate,33.68,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,30.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,5.28,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.28,2247,
HYDRATION INFUSION INITIAL HR,9030010,CDM,260,RC,96360,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,389.61,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
HYDRATION IV INFSN ADDL HR >30 MIN,9030011,CDM,260,RC,96361,HCPCS,Outpatient,,,125,75,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.5,70,,,percent of total billed charges,70% of total billed charges,93.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,100,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,95.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,21.54,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,56.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,75,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,87.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,60,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,112.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,19.59,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,19.59,334,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",9030012,CDM,260,RC,96365,HCPCS,Outpatient,,,630,378,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,441,70,,,percent of total billed charges,70% of total billed charges,472.5,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,504,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,481.95,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,108.55,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,283.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,378,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,441,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,567,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,98.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,98.72,664.77,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",9030013,CDM,260,RC,96366,HCPCS,Outpatient,,,165,99,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,123.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,132,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,126.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,28.43,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,99,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,115.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,79.2,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,148.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.86,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,25.86,334,
SEQ NONCHEMO INFSN ADDL HR DIFFRNT DRUG,9030014,CDM,260,RC,96367,HCPCS,Outpatient,,,275,165,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,118.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,70,,,percent of total billed charges,70% of total billed charges,206.25,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,220,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.55,103,,,Fee Schedule,103% of CMS OPPS Rate,210.38,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,47.38,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,123.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,165,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,334,100,,,Case rate,Pays based on per visit ,192.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,247.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,43.09,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,43.09,334,
CONCURRENT NONCHEMO INFUSION ADDL HR,9030015,CDM,260,RC,96368,HCPCS,Outpatient,,,64.35,38.61,,11.58,18,,,percent of total billed charges,pays at 18% of total charges,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.58,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.05,70,,,percent of total billed charges,70% of total billed charges,48.26,75,,,percent of total billed charges,75% of total billed charges,32.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,51.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,49.23,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,11.09,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.96,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.61,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,334,100,,,Case rate,Pays based on per visit ,45.05,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.89,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,64.35,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,57.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,10.08,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,334,
INJECTION SQ OR IM,9030016,CDM,760,RC,96372,HCPCS,Outpatient,,,255.35,153.21,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges,191.51,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,204.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,195.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,114.91,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.21,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.75,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,229.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,2239,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",9030017,CDM,760,RC,96374,HCPCS,Outpatient,,,497,298.2,,664.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges,372.75,75,,,percent of total billed charges,75% of total billed charges,338.02,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,397.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,657.27,350,,,Fee Schedule,350% of CMS OPPS Rate,191.54,103,,,Fee Schedule,103% of CMS OPPS Rate,380.21,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,223.65,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,431.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,447.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,100,,,Fee Schedule,100% of CMS OPPS Rate,187.79,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",9030018,CDM,760,RC,96375,HCPCS,Outpatient,,,149,89.4,,136.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,38.51,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,104.3,70,,,percent of total billed charges,70% of total billed charges,111.75,75,,,percent of total billed charges,75% of total billed charges,69.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,119.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.81,350,,,Fee Schedule,350% of CMS OPPS Rate,39.28,103,,,Fee Schedule,103% of CMS OPPS Rate,113.99,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,88.59,100,,,Fee Schedule,100% of CMS OPPS Rate,2239,100,,,Case rate,pays based on per visit rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,134.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,100,,,Fee Schedule,100% of CMS OPPS Rate,38.51,2239,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",9030019,CDM,761,RC,96376,HCPCS,Outpatient,,,85.5,51.3,,15.39,18,,,percent of total billed charges,pays at 18% of total charges,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,15.39,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.13,75,,,percent of total billed charges,75% of total billed charges,42.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,68.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,65.41,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,14.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.48,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.3,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.04,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,85.5,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,76.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,13.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.4,85.5,
Immunization administration by a medical assistant or nurse,9030033,CDM,771,RC,90471,HCPCS,Outpatient,,,164,98.4,,217.13,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,61.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82,50,,,percent of total billed charges,pays at 50% of total billed charges,114.8,70,,,percent of total billed charges,70% of total billed charges,123,75,,,percent of total billed charges,75% of total billed charges,110.4,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,131.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,214.67,350,,,Fee Schedule,350% of CMS OPPS Rate,62.56,103,,,Fee Schedule,103% of CMS OPPS Rate,125.46,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,73.8,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,98.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,100,,,Case rate,Pays based on per visit ,114.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,141.07,100,,,Fee Schedule,100% of CMS OPPS Rate,78.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.25,100,,,Case rate,pays based on per visit rate,147.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,42,217.13,
ADJUSTMENT - SMALL BALANCE,9980010,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
IN HOUSE BAD DEBT,9989998,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BAD DEBT WRITE-OFF SYSTEM,9989999,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
RETURNED CHECK,9990136,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
INTEREST RCVD FROM INSURANCE,9990141,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
Test to measure how well gases diffuse across lung surfaces,E4379120,CDM,460,RC,94729,HCPCS,Outpatient,,,214,128.4,,38.52,18,,,percent of total billed charges,pays at 18% of total charges,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.52,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,70,,,percent of total billed charges,70% of total billed charges,160.5,75,,,percent of total billed charges,75% of total billed charges,107,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,171.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,163.71,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,36.87,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.3,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,128.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,422,100,,,Case rate,Pays based on per visit ,149.8,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,214,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,192.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,33.53,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.53,422,
Measures how much air is in the lungs after taking a deep breath,E4379120,CDM,460,RC,94726,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.28,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.58,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
Test to determine if wheezing is present,E4379120,CDM,460,RC,94060,HCPCS,Outpatient,,,685,411,,901.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,254.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,507.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,479.5,70,,,percent of total billed charges,70% of total billed charges,513.75,75,,,percent of total billed charges,75% of total billed charges,458.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,548,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,891.1,350,,,Fee Schedule,350% of CMS OPPS Rate,259.69,103,,,Fee Schedule,103% of CMS OPPS Rate,524.03,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,118.03,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,308.25,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,411,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,422,100,,,Case rate,Pays based on per visit ,479.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,585.57,100,,,Fee Schedule,100% of CMS OPPS Rate,328.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,616.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,107.34,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,254.6,100,,,Fee Schedule,100% of CMS OPPS Rate,107.34,901.29,
ALLOGRAFT EPIFIX MESH 4X4.5 PER SQ CM,JW3616711,CDM,636,RC,Q4131,HCPCS,Outpatient,,,181.22,108.73,,32.62,18,,,percent of total billed charges,pays at 18% of total charges,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,32.62,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,90.61,50,,,percent of total billed charges,pays at 50% of total billed charges,126.85,70,,,percent of total billed charges,70% of total billed charges,135.92,75,,,percent of total billed charges,75% of total billed charges,90.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,144.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,108.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,138.63,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,31.22,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,126.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,108.73,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.85,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.99,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,181.22,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,163.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,28.4,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.4,181.22,
ALLOGRAFT EPIFIX 2X3MM PER SQ CM,JW3616712,CDM,636,RC,Q4131,HCPCS,Outpatient,,,247.85,148.71,,44.61,18,,,percent of total billed charges,pays at 18% of total charges,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,44.61,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,123.93,50,,,percent of total billed charges,pays at 50% of total billed charges,173.5,70,,,percent of total billed charges,70% of total billed charges,185.89,75,,,percent of total billed charges,75% of total billed charges,123.93,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,198.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,148.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,189.61,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,42.7,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.53,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,173.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,148.71,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.5,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.97,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,247.85,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,223.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,38.84,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.84,247.85,
ALLOGRAFT EPIFIX 4X10MM PER SQ CM,JW3616713,CDM,636,RC,Q4131,HCPCS,Outpatient,,,139,83.4,,25.02,18,,,percent of total billed charges,pays at 18% of total charges,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,25.02,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,69.5,50,,,percent of total billed charges,pays at 50% of total billed charges,97.3,70,,,percent of total billed charges,70% of total billed charges,104.25,75,,,percent of total billed charges,75% of total billed charges,69.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,111.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,83.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,106.34,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,23.95,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.55,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,97.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,83.4,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,52.82,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,97.3,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,139,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,125.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,21.78,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.78,139,
ALLOGRAFT EPIFIX 5X18MM PER SQ CM,JW3616714,CDM,636,RC,Q4131,HCPCS,Outpatient,,,386.88,232.13,,69.64,18,,,percent of total billed charges,pays at 18% of total charges,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,69.64,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,193.44,50,,,percent of total billed charges,pays at 50% of total billed charges,270.82,70,,,percent of total billed charges,70% of total billed charges,290.16,75,,,percent of total billed charges,75% of total billed charges,193.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,309.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,295.96,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,66.66,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.1,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,270.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,232.13,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,147.01,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,270.82,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.7,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,386.88,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,348.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,60.62,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.62,386.88,
MATRIX WOUND 3LAYER PER SQ CM WASTE,JW3636825,CDM,636,RC,Q4166,HCPCS,Outpatient,,,63.23,37.94,,11.38,18,,,percent of total billed charges,pays at 18% of total charges,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,11.38,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,31.62,50,,,percent of total billed charges,pays at 50% of total billed charges,44.26,70,,,percent of total billed charges,70% of total billed charges,47.42,75,,,percent of total billed charges,75% of total billed charges,31.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,50.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,48.37,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,10.89,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,44.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,37.94,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,24.03,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,44.26,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.35,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,63.23,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,56.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,9.91,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.91,63.23,
MATRIX WOUND 1 LAYER PER SQ CM,JW3636847,CDM,636,RC,Q4166,HCPCS,Outpatient,,,15.58,9.35,,2.8,18,,,percent of total billed charges,pays at 18% of total charges,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.8,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,7.79,50,,,percent of total billed charges,pays at 50% of total billed charges,10.91,70,,,percent of total billed charges,70% of total billed charges,11.69,75,,,percent of total billed charges,75% of total billed charges,7.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,11.92,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,2.68,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.01,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,10.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,9.35,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,5.92,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,10.91,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,15.58,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,14.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,2.44,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.44,15.58,
MATRIX WOUND 1 LAYER PER SQ CM,JW3636848,CDM,636,RC,Q4166,HCPCS,Outpatient,,,6.1,3.66,,1.1,18,,,percent of total billed charges,pays at 18% of total charges,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,1.1,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,3.05,50,,,percent of total billed charges,pays at 50% of total billed charges,4.27,70,,,percent of total billed charges,70% of total billed charges,4.58,75,,,percent of total billed charges,75% of total billed charges,3.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,4.67,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1.05,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.75,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.66,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,2.32,38,,,percent of total billed charges,38% of total billed charges for outpatient setting,4.27,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.93,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,6.1,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,5.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,0.96,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.96,6.1,
SACITUZUMAB GOVITECAN-HZIY 2.5MG (180MG),JW4300029,CDM,636,RC,J9317,HCPCS,Outpatient,,,0.01,0.01,,117.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,33.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,59.86,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.41,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,76.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,33.26,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,117.74,
DOXORUBICIN HCL 10MG INJ,JW4300148,CDM,636,RC,J9000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN HCL 50MG/ 25ML VIAL,JW4300150,CDM,636,RC,J9000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN LIPOSOM 50 MG,JW4300177,CDM,636,RC,Q2050,HCPCS,Outpatient,,,0.01,0.01,,512.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,260.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,333.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,512.76,
IRINOTACAN 20MG INJ,JW4300228,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB 10MG INJ,JW4300251,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
BEVACIZUMAB-AWWB 10MG INJ (100MG/4ML),JW4300256,CDM,636,RC,Q5107,HCPCS,Outpatient,,,0.01,0.01,,98.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.47,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.58,
OFATUMUMAB 10MG INJ (1000MG VIAL),JW4300258,CDM,636,RC,J9302,HCPCS,Outpatient,,,0.01,0.01,,226.41,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,63.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,115.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,223.86,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,147.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,63.96,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,226.41,
BEVACIZUMAB-AWWB 10MG INJ (400MG/16ML),JW4300272,CDM,636,RC,Q5107,HCPCS,Outpatient,,,0.01,0.01,,98.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,50.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,97.47,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,98.58,
CETUXIMAB 200MG/100ML INJ,JW4300283,CDM,636,RC,J9055,HCPCS,Outpatient,,,0.01,0.01,,255.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,130.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.98,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,166.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,255.87,
CYCLOPHOSPHAMIDE 500MG VL,JW4300287,CDM,636,RC,J9070,HCPCS,Outpatient,,,0.01,0.01,,63.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,32.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.79,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,63.5,
PACLITAXEL PROTEIN-BOUND 1MG,JW4300294,CDM,636,RC,J9264,HCPCS,Outpatient,,,0.01,0.01,,52.35,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,26.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,34.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,52.35,
CYCLOPHOSPHAMIDE 2GM VL,JW4300311,CDM,636,RC,J9070,HCPCS,Outpatient,,,489.6,293.76,,63.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,244.8,50,,,percent of total billed charges,pays at 50% of total billed charges,342.72,70,,,percent of total billed charges,70% of total billed charges,367.2,75,,,percent of total billed charges,75% of total billed charges,32.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,391.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.79,350,,,Fee Schedule,350% of CMS OPPS Rate,18.29,103,,,Fee Schedule,103% of CMS OPPS Rate,374.54,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,84.36,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,220.32,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,342.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,293.76,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,35.22,100,,,Fee Schedule,100% of UHC Fee Schedule,342.72,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.26,100,,,Fee Schedule,100% of CMS OPPS Rate,235.01,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,440.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,76.72,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,440.64,
DOXORUBICIN 200MG/100ML VL,JW4300312,CDM,636,RC,J9000,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
INTERFERON ALFA-2B 10MIU,JW4300319,CDM,636,RC,J9214,HCPCS,Outpatient,,,0.01,0.01,,115.29,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,113.99,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,74.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.29,
ROMIPLASTIN 250MCG INJ,JW4300327,CDM,636,RC,J2796,HCPCS,Outpatient,,,0.01,0.01,,338.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.12,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,220.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.95,
OXALIPLATIN 50MG INJ,JW4300328,CDM,636,RC,J9263,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENDAMASTINE 100MG INJ,JW4300336,CDM,636,RC,J9033,HCPCS,Outpatient,,,0.01,0.01,,40.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,20.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,40.42,
BENDAMASTINE 25MG INJ,JW4300337,CDM,636,RC,J9033,HCPCS,Outpatient,,,0.01,0.01,,40.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,20.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,40.42,
EPIRUBICIN 50MG/25ML VIAL,JW4300346,CDM,636,RC,J9178,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BENDAMASTINE 180MG INJ,JW4300400,CDM,636,RC,J9033,HCPCS,Outpatient,,,0.01,0.01,,40.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,20.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,40.42,
BENDAMASTINE 45MG INJ,JW4300401,CDM,636,RC,J9033,HCPCS,Outpatient,,,0.01,0.01,,40.42,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,20.55,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,26.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,11.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,40.42,
BENDAMASTINE 100 MG/4ML MDV (BENDEKA),JW4300402,CDM,636,RC,J9034,HCPCS,Outpatient,,,0.01,0.01,,56.14,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,28.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,55.51,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,36.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,15.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,56.14,
ELOTUZUMAB 1MG INJ 300MG VIAL,JW4300556,CDM,636,RC,J9176,HCPCS,Outpatient,,,0.01,0.01,,25.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.55,
ELOTUZUMAB 1MG INJ 400MG VIAL,JW4300557,CDM,636,RC,J9176,HCPCS,Outpatient,,,0.01,0.01,,25.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,12.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,16.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.55,
BLEOMYCIN 15 UNITS (15UNITS) INJ,JW4301138,CDM,636,RC,J9040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
CLOFARABINE 20 MG/20 ML VIAL,JW4301230,CDM,636,RC,J9027,HCPCS,Outpatient,,,0.01,0.01,,82.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,41.92,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,81.51,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,53.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,82.44,
DURVALUMAB 10MG INJ (120MG),JW4301231,CDM,636,RC,J9173,HCPCS,Outpatient,,,0.01,0.01,,282.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,143.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.08,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,183.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,282.27,
TRASTUZUMAB-ANNS 10MG INJ (150MG),JW4301255,CDM,636,RC,Q5117,HCPCS,Outpatient,,,0.01,0.01,,86.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,86.16,
INFLIXIMAB BIOSIMILAR 10MG INJ 100MG VL,JW4301289,CDM,636,RC,Q5103,HCPCS,Outpatient,,,0.01,0.01,,49.31,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,25.07,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,48.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,32.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,13.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,49.31,
A biologic medication,JW4301291,CDM,636,RC,J1745,HCPCS,Outpatient,,,0.01,0.01,,115.54,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,58.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,114.24,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,75.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,115.54,
TRASTUZUMAB 10MG INJ 150MG VIAL,JW4301460,CDM,636,RC,J9355,HCPCS,Outpatient,,,0.01,0.01,,285.99,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,145.41,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,282.76,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,185.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,80.79,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,285.99,
TRASTUZUMAB-ANNS 10MG INJ (420MG),JW4301464,CDM,636,RC,Q5117,HCPCS,Outpatient,,,0.01,0.01,,86.16,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,43.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,24.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,86.16,
OMALIZUMAB 5MG INJ (150MG VIAL),JW4301604,CDM,636,RC,J2357,HCPCS,Outpatient,,,0.01,0.01,,138.37,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.36,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,136.81,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,89.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.37,
OXALIPLATIN 100MG VIAL,JW4301801,CDM,636,RC,J9263,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BEVACIZUMAB 400MG/16ML,JW4301803,CDM,636,RC,J9035,HCPCS,Outpatient,,,0.01,0.01,,261.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,132.85,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,258.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,169.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,73.81,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,261.27,
TOPOTECAN 4MG VIAL,JW4301834,CDM,636,RC,J9351,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTECAN 100MG INJ,JW4301836,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTECAN LIPOSOME 1MG (43MG/10ML) INJ,JW4301837,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FERRIC DERISOMALTOSE 10MG INJ 10 ML,JW4301839,CDM,636,RC,J1437,HCPCS,Outpatient,,,0.01,0.01,,71.01,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,36.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,46.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,20.05,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,71.01,
ISATUXIMAB-IRFC 10 MG INJ (100 MG),JW4301844,CDM,636,RC,J9227,HCPCS,Outpatient,,,0.01,0.01,,240.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,122.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,156.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,240.2,
ISATUXIMAB-IRFC 10 MG INJ (500 MG),JW4301845,CDM,636,RC,J9227,HCPCS,Outpatient,,,0.01,0.01,,240.2,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,122.13,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,237.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,156.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,240.2,
ENFORTUMAB VED-EJFV  0.25 MG INJ (20 MG),JW4301853,CDM,636,RC,J9177,HCPCS,Outpatient,,,0.01,0.01,,124.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,63.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,124.11,
EPIRUBICIN 2MG/ML 100ML,JW4301855,CDM,636,RC,J9178,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ENFORTUMAB VED-EJFV 0.25 MG INJ (30 MG),JW4301858,CDM,636,RC,J9177,HCPCS,Outpatient,,,0.01,0.01,,124.11,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,63.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.71,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,35.06,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,124.11,
ROMIDEPSIN 0.1 MG INJ 10 MG,JW4301881,CDM,636,RC,J9319,HCPCS,Outpatient,,,0.01,0.01,,108.53,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.66,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,55.18,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,107.31,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,70.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,30.66,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,108.53,
EFGARTIGIMOD ALFA-FCAB 2 MG INJ 20 ML,JW4301883,CDM,636,RC,J9332,HCPCS,Outpatient,,,0.01,0.01,,113.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,32.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,57.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,112.38,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,73.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,113.66,
GEMCITABINE 1GM INJ,JW4301898,CDM,636,RC,J9201,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GEMCITABINE 200MG INJ,JW4301900,CDM,636,RC,J9201,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
DOXORUBICIN LIPOSOM 20MG,JW4301908,CDM,636,RC,Q2050,HCPCS,Outpatient,,,0.01,0.01,,512.76,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,260.73,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,506.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,333.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,512.76,
INFLIXMAB-AXXQ BIOSIM 10 MG (100MG) INJ,JW4301935,CDM,636,RC,Q5121,HCPCS,Outpatient,,,0.01,0.01,,93.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,47.64,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.64,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,60.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,93.7,
BELANTAMAB MAF-BLMF 0.5 MG INJ 100 MG,JW4301959,CDM,636,RC,J9037,HCPCS,Outpatient,,,0.01,0.01,,165.6,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.78,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.72,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,107.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,46.78,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,165.6,
CETUXIMAB 2MG/ML-50ML,JW4301976,CDM,636,RC,J9055,HCPCS,Outpatient,,,0.01,0.01,,255.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,130.1,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,252.98,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,166.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,72.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,255.87,
CARFILZOMIB 1MG (60MG) INJ,JW4302019,CDM,636,RC,J9047,HCPCS,Outpatient,,,0.01,0.01,,166.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,107.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,166.02,
CARFILZOMIB 1MG (30MG) INJ,JW4302021,CDM,636,RC,J9047,HCPCS,Outpatient,,,0.01,0.01,,166.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,107.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,166.02,
CARFILZOMIB 1MG (10MG) INJ,JW4302022,CDM,636,RC,J9047,HCPCS,Outpatient,,,0.01,0.01,,166.02,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,84.42,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,164.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,107.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,166.02,
CYCLOPHOSPHAMIDE 1GM INJ,JW4302282,CDM,636,RC,J9070,HCPCS,Outpatient,,,0.01,0.01,,63.5,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,32.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.79,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,41.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,63.5,
ZOLEDRONIC ACID 4MG/5ML,JW4302573,CDM,636,RC,J3489,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RITUXIMAB 10MG INJ (500MG VIAL),JW4302605,CDM,636,RC,J9312,HCPCS,Outpatient,,,0.01,0.01,,283.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,144.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,184.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,283.87,
RITUXIMAB 10MG INJ (100MG VIAL),JW4302625,CDM,636,RC,J9312,HCPCS,Outpatient,,,0.01,0.01,,283.87,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,144.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,280.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,184.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,283.87,
CABAZITAXEL 60MG/1.5ML,JW4302657,CDM,636,RC,J9043,HCPCS,Outpatient,,,0.01,0.01,,741.06,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,209.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,376.81,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,732.69,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,481.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,209.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,741.06,
DURVALUMAB 10MG INJ (500MG),JW4302718,CDM,636,RC,J9173,HCPCS,Outpatient,,,0.01,0.01,,282.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,143.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,279.08,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,183.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,79.73,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,282.27,
IMMUNE GLOBULIN 10% 500MG (10GM/100ML),JW4302997,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
"EPOETIN BIOSIMILAR 1000 UNITS (40,000IU)",JW4303004,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
"EPOETIN BIOSIMILAR 1000 UNITS (10,000IU)",JW4303005,CDM,636,RC,Q5106,HCPCS,Outpatient,,,0.01,0.01,,25.66,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,13.05,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.37,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,16.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,7.25,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,25.66,
DACARBAZINE 200MG INJ,JW4303048,CDM,636,RC,J9130,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
FAM-TRASTUZUMAB DERUXTECAN-NXKI 1MG INJ,JW4303236,CDM,636,RC,J9358,HCPCS,Outpatient,,,0.01,0.01,,93.38,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,26.38,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,47.48,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,92.33,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,60.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,93.38,
CRIZANLIZUMAB-TMCA 1MG INJ (100MG),JW4303237,CDM,636,RC,C9053,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
PEMBROLIZUMAB 1MG INJ (100MG VIAL),JW4303266,CDM,636,RC,J9271,HCPCS,Outpatient,,,0.01,0.01,,199.69,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,101.53,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,197.43,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,129.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,56.41,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,199.69,
BOTULINUM TOXIN A 100UNIT,JW4303326,CDM,636,RC,J0585,HCPCS,Outpatient,,,0.01,0.01,,22.4,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.15,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,22.4,
USTEKINUMAB 1MG INJ (130MG/26ML),JW4303359,CDM,636,RC,J3358,HCPCS,Outpatient,,,0.01,0.01,,44.67,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,22.71,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.17,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,29.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,44.67,
TOCILIZUMAB 1MG INJ (80MG VIAL),JW4303503,CDM,636,RC,J3262,HCPCS,Outpatient,,,0.01,0.01,,21.91,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,11.14,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,14.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,21.91,
OLARATUMAB 10MG INJ (190MG VIAL),JW4303505,CDM,636,RC,J9285,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IRINOTECAN 300MG/15ML VIAL,JW4303595,CDM,636,RC,J9206,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ROMIPLOSTIM 12.5MCG INJ (125MCG),JW4303720,CDM,636,RC,J2796,HCPCS,Outpatient,,,0.01,0.01,,338.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,172.35,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.12,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,220.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,95.75,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,338.95,
BRENTUXIMAB 50MG VIAL,JW4303727,CDM,636,RC,J9042,HCPCS,Outpatient,,,0.01,0.01,,786.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,222.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,399.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,777.38,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,510.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,222.11,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,786.26,
NIVOLUMAB 40MG/ 4ML VIAL,JW4303750,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
NIVOLUMAB 100MG/ 10ML VIAL,JW4303752,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
NIVOLUMAB 1MG INJ (240MG/24ML),JW4303754,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
FERRIC CARBOXYMALTOSE 750MG/15ML VIAL,JW4304083,CDM,636,RC,J1439,HCPCS,Outpatient,,,0.01,0.01,,3.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.92,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,2.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,1.12,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3.96,
IXABEPILONE 15MG/KIT,JW4304115,CDM,636,RC,J9207,HCPCS,Outpatient,,,0.01,0.01,,451.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,229.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,293.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,451.59,
DECITABINE 50MG VIAL,JW4304235,CDM,636,RC,J0894,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AGALSIDASE 1 MG (35MG) INJ,JW4304239,CDM,636,RC,J0180,HCPCS,Outpatient,,,0.01,0.01,,770.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,391.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,761.6,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,500.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,770.3,
AGALSIDASE 1 MG (5MG) INJ,JW4304240,CDM,636,RC,J0180,HCPCS,Outpatient,,,0.01,0.01,,770.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,391.68,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,761.6,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,500.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,217.6,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,770.3,
IFOSFAMIDE 3GM VIAL,JW4304450,CDM,636,RC,J9208,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
BLEOMYCIN 15UNITS (30UNITS) INJ,JW4304452,CDM,636,RC,J9040,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
IFOSFAMIDE 1GM VIAL,JW4304453,CDM,636,RC,J9208,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
ALTEPLASE 1MG INJ (50MG VIAL),JW4304715,CDM,636,RC,J2997,HCPCS,Outpatient,,,0.01,0.01,,315.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,315.62,
ALTEPLASE 1MG INJ (100MG VIAL),JW4304738,CDM,636,RC,J2997,HCPCS,Outpatient,,,0.01,0.01,,315.62,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,160.47,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,312.06,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,205.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,89.16,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,315.62,
PEMETREXED 500MG VIAL,JW4304759,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
CIPROFLOXACIN 6% 1ML OTIC DROPS,JW4304915,CDM,637,RC,J7342,HCPCS,Outpatient,,,0.01,0.01,,106.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.03,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.07,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,69.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.02,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,106.27,
DAPTOMYCIN 1MG (500MG) INJ,JW4305391,CDM,636,RC,J0878,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
GOLIMUMAB 1MG FOR IV USE,JW4305648,CDM,636,RC,J1602,HCPCS,Outpatient,,,0.01,0.01,,45.77,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,23.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.25,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,29.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.93,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,45.77,
PERTUZUMAB 1MG (420MG) INJ,JW4305731,CDM,636,RC,J9306,HCPCS,Outpatient,,,0.01,0.01,,54.58,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,27.75,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,53.97,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,35.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,15.42,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,54.58,
NIVOLUMAB 1 MG INJ (120MG/ 12ML),JW4305761,CDM,636,RC,J9299,HCPCS,Outpatient,,,0.01,0.01,,107.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,54.77,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,106.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,69.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,30.43,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,107.72,
BELIMUMAB 10MG INJ (400MG),JW4305847,CDM,636,RC,J0490,HCPCS,Outpatient,,,0.01,0.01,,183.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,93.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.89,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,119.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,51.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,183.97,
AVELUMAB 200 MG/10 ML VIAL SDV,JW4305855,CDM,636,RC,J9023,HCPCS,Outpatient,,,0.01,0.01,,321.75,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,163.6,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,318.11,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,209.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,90.89,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,321.75,
ARSENIC TRIOXIDE 10MG/10ML,JW4306002,CDM,636,RC,J9017,HCPCS,Outpatient,,,0.01,0.01,,65.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,33.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,42.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,65.48,
ARSENIC TRIOXIDE 1MG INJ (12MG/6ML),JW4306008,CDM,636,RC,J9017,HCPCS,Outpatient,,,0.01,0.01,,65.48,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,33.29,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,64.75,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,42.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,18.5,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,65.48,
NECITUMUMAB 1MG INJ 800MG VIAL,JW4306016,CDM,636,RC,J9295,HCPCS,Outpatient,,,0.01,0.01,,20.3,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,10.33,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.09,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,13.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,5.74,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,20.3,
IPILIMUMAB 50MG VIAL,JW4306327,CDM,636,RC,J9228,HCPCS,Outpatient,,,0.01,0.01,,596.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,303.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,387.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,596.7,
IPILIMUMAB 200MG VIAL,JW4306328,CDM,636,RC,J9228,HCPCS,Outpatient,,,0.01,0.01,,596.7,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,303.39,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,589.96,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,387.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,168.56,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,596.7,
DARBEPOETIN 1MCG (60MCG) INJ,JW4306371,CDM,636,RC,J0881,HCPCS,Outpatient,,,0.01,0.01,,10.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.31,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,6.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,2.95,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,10.44,
ERIBULIN MESYLATE 0.1MG INJ,JW4306385,CDM,636,RC,J9179,HCPCS,Outpatient,,,0.01,0.01,,463.27,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,130.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,235.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,458.04,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,301,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,130.87,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,463.27,
IXABEPILONE 45MG/KIT,JW4306589,CDM,636,RC,J9207,HCPCS,Outpatient,,,0.01,0.01,,451.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,229.62,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,446.49,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,293.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,451.59,
IMMUNE GLOBULIN 10% 500MG (5GM/50ML),JW4306653,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
IMMUNE GLOBULIN 10% 500MG (20GM/200ML),JW4306654,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
IMMUNE GLOBULIN 10% 500MG (40GM/400ML),JW4306655,CDM,636,RC,J1459,HCPCS,Outpatient,,,0.01,0.01,,168.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,85.66,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,166.56,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,168.46,
ADO-TRASTUZUMAB EMTANSINE 1MG INJ,JW4306789,CDM,636,RC,J9354,HCPCS,Outpatient,,,0.01,0.01,,135.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,69.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,135.72,
ADO-TRASTUZUMAB EMTANSINE 160MG INJ,JW4306790,CDM,636,RC,J9354,HCPCS,Outpatient,,,0.01,0.01,,135.72,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,69.01,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,134.19,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,135.72,
BORTEZOMIB 3.5MG VIAL,JW4307031,CDM,636,RC,J9041,HCPCS,Outpatient,,,0.01,0.01,,8.1,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,4.12,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,2.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,8.1,
CLADRIBINE 10MG/10ML,JW4307046,CDM,636,RC,J9065,HCPCS,Outpatient,,,0.01,0.01,,59.33,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,30.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58.66,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,38.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,16.76,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,59.33,
PENTAMIDINE 300MG SOLN,JW4307190,CDM,636,RC,J7676,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
NELARABINE 50MG (250MG/50ML) INJ,JW4307224,CDM,636,RC,J9261,HCPCS,Outpatient,,,0.01,0.01,,412.94,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,116.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,209.97,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,408.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,268.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,116.65,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,412.94,
ROMIDEPSIN 10MG KIT,JW4307391,CDM,636,RC,J9315,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
RAMUCIRUMAB 100MG/10ML VIAL,JW4307536,CDM,636,RC,J9308,HCPCS,Outpatient,,,0.01,0.01,,244.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,124.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,158.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,244.26,
RAMUCIRUMAB 500MG/50ML VIAL,JW4307537,CDM,636,RC,J9308,HCPCS,Outpatient,,,0.01,0.01,,244.26,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,124.2,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,241.5,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,69,100,,,Fee Schedule,100% of CMS OPPS Rate,158.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,69,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,244.26,
OLARATUMAB 500 MG/50 ML VIAL,JW4307610,CDM,636,RC,J9285,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TENECTEPLASE 1 MG (50MG KIT),JW4307924,CDM,636,RC,J3101,HCPCS,Outpatient,,,0.01,0.01,,541.97,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,153.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,275.58,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,535.85,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,352.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,153.1,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,541.97,
PERFLUTREN LIPID MICROSHERE 1.1MG/ML,JW4308315,CDM,636,RC,Q9957,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AZACTIDINE 100MG VIAL,JW4308352,CDM,636,RC,J9025,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LURBINECTEDIN 0.1 MG INJ (4 MG),JW4308413,CDM,636,RC,J9223,HCPCS,Outpatient,,,0.01,0.01,,696.74,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,196.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,354.27,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,688.87,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,452.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,196.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,696.74,
RESLIZUMAB 1MG INJ (100MG VIAL),JW4308450,CDM,636,RC,J2786,HCPCS,Outpatient,,,0.01,0.01,,36.46,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,18.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,36.04,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,23.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,36.46,
PEMETREXED 100MG VIAL,JW4308671,CDM,636,RC,J9305,HCPCS,Outpatient,,,0.01,0.01,,11.39,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,5.79,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.27,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3.22,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,11.39,
PRALATREXATE 1 MG (20MG/ML) VIAL,JW4308818,CDM,636,RC,J9307,HCPCS,Outpatient,,,0.01,0.01,,1055.55,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,298.18,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,536.72,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1043.63,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,685.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,298.18,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,1055.55,
DIPHENHYDRAMINE 50MG/ML (10ML) INJ,JW4309074,CDM,636,RC,J1200,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TOPOTECAN 0.1MG INJ (4MG VIAL),JW4309617,CDM,636,RC,J9351,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AFLIBERCEPT 1MG (2MG INJ),JW4309721,CDM,636,RC,J0178,HCPCS,Outpatient,,,0.01,0.01,,3073.56,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,868.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,1562.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3038.84,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1996.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,868.24,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,3073.56,
DOCETAXEL 1MG INJ (80MG/8ML),JW4309729,CDM,636,RC,J9171,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
VINORELBINE 10MG (50MG) INJ,JW4309732,CDM,636,RC,J9390,HCPCS,Outpatient,,,0.01,0.01,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
LUSPATERCEPT-AAMT 0.25MG INJ (75 MG),JW4309793,CDM,636,RC,J0896,HCPCS,Outpatient,,,0.01,0.01,,138.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.22,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,90.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.8,
LUSPATERCEPT-AAMT 0.25MG INJ (25 MG),JW4309796,CDM,636,RC,J0896,HCPCS,Outpatient,,,0.01,0.01,,138.8,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,70.56,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137.22,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,90.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,39.21,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,138.8,
CRIZANLIZUMAB-TMCA 5 MG INJ (100),JW4309801,CDM,636,RC,J0791,HCPCS,Outpatient,,,0.01,0.01,,449.08,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,126.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,228.34,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,444.01,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,126.86,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,449.08,
OCRELIZUMAB 300 MG/10 ML VIAL,JW4309908,CDM,636,RC,J2350,HCPCS,Outpatient,,,0.01,0.01,,214.34,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,60.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,0.01,50,,,percent of total billed charges,pays at 50% of total billed charges,0.01,70,,,percent of total billed charges,70% of total billed charges,0.01,75,,,percent of total billed charges,75% of total billed charges,108.99,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.92,350,,,Fee Schedule,350% of CMS OPPS Rate,0.01,103,,,Fee Schedule,103% of CMS OPPS Rate,0.01,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,0.01,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of UHC Fee Schedule,0.01,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,139.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,60.55,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,214.34,
Radiologic examination of one side of the chest/ribs,R201101,CDM,320,RC,71101,HCPCS,Outpatient,,,350,210,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245,70,,,percent of total billed charges,70% of total billed charges,262.5,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,280,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,267.75,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,60.31,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,157.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,210,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,245,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,168,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,315,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,54.85,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,54.85,364,
Radiologic examination of the knee with 3 views,R203562,CDM,320,RC,73562,HCPCS,Outpatient,,,293.15,175.89,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.21,70,,,percent of total billed charges,70% of total billed charges,219.86,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,234.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,224.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,50.51,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,131.92,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,205.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,175.89,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,364,100,,,Case rate,Pays based on per visit ,205.21,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,140.71,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,263.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,45.94,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,45.94,364,
US BREAST UNILAT COMPLETE RT,R236641,CDM,402,RC,76641,HCPCS,Outpatient,,,415.8,249.48,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,291.06,70,,,percent of total billed charges,70% of total billed charges,311.85,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,332.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,318.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,187.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,199.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,374.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,65.16,446,
Limited ultrasound of the breast,R236642,CDM,402,RC,76642,HCPCS,Outpatient,,,415.8,249.48,,279.59,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,78.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.66,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,291.06,70,,,percent of total billed charges,70% of total billed charges,311.85,75,,,percent of total billed charges,75% of total billed charges,142.16,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,332.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,276.43,350,,,Fee Schedule,350% of CMS OPPS Rate,80.56,103,,,Fee Schedule,103% of CMS OPPS Rate,318.09,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,71.64,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,187.11,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,249.48,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,291.06,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,181.65,100,,,Fee Schedule,100% of CMS OPPS Rate,199.58,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,374.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,65.16,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,78.98,100,,,Fee Schedule,100% of CMS OPPS Rate,65.16,446,
US EXTREMITY NON-VASCULAR RT,R236881,CDM,402,RC,76881,HCPCS,Outpatient,,,532.4,319.44,,343.95,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,372.68,70,,,percent of total billed charges,70% of total billed charges,399.3,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,425.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,407.29,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,91.73,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,239.58,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,372.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,319.44,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,372.68,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,255.55,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,479.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,83.43,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,479.16,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",R236882,CDM,402,RC,76882,HCPCS,Outpatient,,,303,181.8,,343.96,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.16,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,233.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,212.1,70,,,percent of total billed charges,70% of total billed charges,227.25,75,,,percent of total billed charges,75% of total billed charges,174.89,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,242.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,340.07,350,,,Fee Schedule,350% of CMS OPPS Rate,99.1,103,,,Fee Schedule,103% of CMS OPPS Rate,231.8,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,52.21,17.23,,,percent of total billed charges,17.23% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,136.35,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,181.8,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,212.1,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,223.47,100,,,Fee Schedule,100% of CMS OPPS Rate,145.44,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,272.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,47.48,15.67,,,percent of total billed charges,15.67% of total billed charges for outpatient setting,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,97.16,100,,,Fee Schedule,100% of CMS OPPS Rate,47.48,446,
US GUIDED CYST ASPIRATION RT,R239001,CDM,402,RC,19000,HCPCS,Outpatient,,,1651,990.6,,2088.52,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,1651,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,589.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1167.98,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,1155.7,70,,,percent of total billed charges,70% of total billed charges,1238.25,75,,,percent of total billed charges,75% of total billed charges,1061.95,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,1320.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2064.92,350,,,Fee Schedule,350% of CMS OPPS Rate,601.77,103,,,Fee Schedule,103% of CMS OPPS Rate,1263.02,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,742.95,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,990.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,446,100,,,Case rate,Pays based on per visit ,1155.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.95,100,,,Fee Schedule,100% of CMS OPPS Rate,792.48,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,1651,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,589.97,100,,,Fee Schedule,100% of CMS OPPS Rate,446,2088.52,
US GUIDED CYST ASP EACH ADDITIONAL  RT,R239002,CDM,402,RC,19001,HCPCS,Outpatient,,,252,151.2,,45.36,18,,,percent of total billed charges,pays at 18% of total charges,252,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,45.36,18,,,percent of total billed charges,18% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.4,70,,,percent of total billed charges,70% of total billed charges,189,75,,,percent of total billed charges,75% of total billed charges,126,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,201.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,192.78,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,151.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,446,100,,,Case rate,Pays based on per visit ,176.4,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.96,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,252,100,,,percent of total billed charges,100% of total billed charges for outpatient setting,226.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,252,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.36,446,
REMOVAL OF BREAST LESION,R239120,CDM,360,RC,19120,HCPCS,Outpatient,,,5467,3280.2,,11063.57,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,3125.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5450.55,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,3826.9,70,,,percent of total billed charges,70% of total billed charges,4100.25,75,,,percent of total billed charges,75% of total billed charges,5625.54,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,4373.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10938.56,350,,,Fee Schedule,350% of CMS OPPS Rate,3187.8,103,,,Fee Schedule,103% of CMS OPPS Rate,4182.26,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2460.15,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,3826.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3280.2,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,3826.9,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,7188.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2624.16,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4920.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,3125.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665,11063.57,
IM - KNEE COMPLETE RIGHT,R299390,CDM,900,RC,,,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278,278,
BONE MARROW BIOPSY RT,R548221,CDM,360,RC,38221,HCPCS,Outpatient,,,4221,2532.6,,4825.85,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1363.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2693.53,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,2954.7,70,,,percent of total billed charges,70% of total billed charges,3165.75,75,,,percent of total billed charges,75% of total billed charges,2453.83,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,3376.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4771.33,350,,,Fee Schedule,350% of CMS OPPS Rate,1390.5,103,,,Fee Schedule,103% of CMS OPPS Rate,3229.07,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1899.45,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,2954.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2532.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,2954.7,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3135.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2026.08,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,3798.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,1363.24,100,,,Fee Schedule,100% of CMS OPPS Rate,915,4825.85,
BONE MARROW BIOSPY/ ASP,R548223,CDM,360,RC,38222,HCPCS,Outpatient,,,7110,4266,,8313.44,354,,,Fee Schedule,Pays at 354% of MEDICARE|MEDICARE CMS OPPS rate,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,2348.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1236.82,100,,,Fee Schedule,pays at 100% of ASC Tier Grouping ,4977,70,,,percent of total billed charges,70% of total billed charges,5332.5,75,,,percent of total billed charges,75% of total billed charges,4227.17,180,,,Fee Schedule,pays at 180% of CMS Fee Schedule,5688,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8219.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2395.39,103,,,Fee Schedule,103% of CMS OPPS Rate,5439.15,76.5,,,percent of total billed charges,76.5% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3199.5,45,,,percent of total billed charges,45% of total billed charges for outpatient setting,4977,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,4266,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1280,100,,,Fee Schedule,100% of UHC ASC Tier Grouping ,4977,70,,,percent of total billed charges,70% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5401.39,100,,,Fee Schedule,100% of CMS OPPS Rate,3412.8,48,,,percent of total billed charges,48% of total billed charges for outpatient setting,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,6399,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2348.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.82,8313.44,
Incision and drainage of abscess; simple or single and complex or multiple,1000005,CDM,983,RC,10060,HCPCS,Outpatient,,,375,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.25,55,,,percent of total billed charges,55% of total billed charges,206.25,55,,,percent of total billed charges,55% of total billed charges,145.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.2,180,,,Fee Schedule,180% of CMS Fee Schedule,134.76,350,,,Fee Schedule,350% of CMS OPPS Rate,96.26,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.15,100,,,Fee Schedule,100% of Fee Schedule,145.35,100,,,Fee Schedule,100% of Fee Schedule,145.35,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,173.65,100,,,Fee Schedule,100% of UHC Fee Schedule,173.65,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.26,206.25,
INCISION&DRAINAGE ABSCESS COMPLICATED/MU,1000006,CDM,983,RC,10061,HCPCS,Outpatient,,,658,394.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,361.9,55,,,percent of total billed charges,55% of total billed charges,361.9,55,,,percent of total billed charges,55% of total billed charges,269.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,269.14,180,,,Fee Schedule,180% of CMS Fee Schedule,249.62,350,,,Fee Schedule,350% of CMS OPPS Rate,178.3,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.83,100,,,Fee Schedule,100% of Fee Schedule,269.23,100,,,Fee Schedule,100% of Fee Schedule,269.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,325.15,100,,,Fee Schedule,100% of UHC Fee Schedule,325.15,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.3,361.9,
INCISION&REMOVAL FOREIGN BODY SUBQ TISS,1000009,CDM,983,RC,10120,HCPCS,Outpatient,,,480,288,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,264,55,,,percent of total billed charges,55% of total billed charges,264,55,,,percent of total billed charges,55% of total billed charges,152.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,147.92,180,,,Fee Schedule,180% of CMS Fee Schedule,141.62,350,,,Fee Schedule,350% of CMS OPPS Rate,101.16,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.87,100,,,Fee Schedule,100% of Fee Schedule,152.75,100,,,Fee Schedule,100% of Fee Schedule,152.75,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,181.48,100,,,Fee Schedule,100% of UHC Fee Schedule,181.48,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.16,264,
"Incision and drainage of hematoma, seroma or fluid collection",1000011,CDM,983,RC,10140,HCPCS,Outpatient,,,519,311.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,285.45,55,,,percent of total billed charges,55% of total billed charges,285.45,55,,,percent of total billed charges,55% of total billed charges,177.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,192.6,180,,,Fee Schedule,180% of CMS Fee Schedule,164.32,350,,,Fee Schedule,350% of CMS OPPS Rate,117.37,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.72,100,,,Fee Schedule,100% of Fee Schedule,177.23,100,,,Fee Schedule,100% of Fee Schedule,177.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.71,100,,,Fee Schedule,100% of UHC Fee Schedule,124.71,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.37,285.45,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",1000034,CDM,983,RC,11102,HCPCS,Outpatient,,,279.63,167.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,153.8,55,,,percent of total billed charges,55% of total billed charges,153.8,55,,,percent of total billed charges,55% of total billed charges,60.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,56.2,350,,,Fee Schedule,350% of CMS OPPS Rate,40.14,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.78,60,,,percent of total billed charges,60% of total billed charges,60.61,100,,,Fee Schedule,100% of Fee Schedule,60.61,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,93.6,100,,,Fee Schedule,100% of UHC Fee Schedule,93.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.14,167.78,
PUNCH BIOPSY OF THE SKIN,1000036,CDM,983,RC,11104,HCPCS,Outpatient,,,351.42,210.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.28,55,,,percent of total billed charges,55% of total billed charges,193.28,55,,,percent of total billed charges,55% of total billed charges,76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,70.46,350,,,Fee Schedule,350% of CMS OPPS Rate,50.33,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.85,60,,,percent of total billed charges,60% of total billed charges,76,100,,,Fee Schedule,100% of Fee Schedule,76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,117.52,100,,,Fee Schedule,100% of UHC Fee Schedule,117.52,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.33,210.85,
PUNCH BIOPSY OF SKIN INCLUDING SIMPLE CL,1000037,CDM,983,RC,11105,HCPCS,Outpatient,,,175,105,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.25,55,,,percent of total billed charges,55% of total billed charges,96.25,55,,,percent of total billed charges,55% of total billed charges,41.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,38.42,350,,,Fee Schedule,350% of CMS OPPS Rate,27.44,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,60,,,percent of total billed charges,60% of total billed charges,41.43,100,,,Fee Schedule,100% of Fee Schedule,41.43,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,56.89,100,,,Fee Schedule,100% of UHC Fee Schedule,56.89,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.44,105,
"Removal of skin tags, multiple fibrocutaneous tags, any area",1000038,CDM,983,RC,11200,HCPCS,Outpatient,,,282,169.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.1,55,,,percent of total billed charges,55% of total billed charges,155.1,55,,,percent of total billed charges,55% of total billed charges,108.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.32,180,,,Fee Schedule,180% of CMS Fee Schedule,100.23,350,,,Fee Schedule,350% of CMS OPPS Rate,71.59,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.06,100,,,Fee Schedule,100% of Fee Schedule,108.1,100,,,Fee Schedule,100% of Fee Schedule,108.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.81,100,,,Fee Schedule,100% of UHC Fee Schedule,124.81,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.59,155.1,
SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM,1000040,CDM,983,RC,11300,HCPCS,Outpatient,,,303,181.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,166.65,55,,,percent of total billed charges,55% of total billed charges,166.65,55,,,percent of total billed charges,55% of total billed charges,53.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.09,180,,,Fee Schedule,180% of CMS Fee Schedule,49.88,350,,,Fee Schedule,350% of CMS OPPS Rate,35.63,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.71,100,,,Fee Schedule,100% of Fee Schedule,53.8,100,,,Fee Schedule,100% of Fee Schedule,53.8,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.65,100,,,Fee Schedule,100% of UHC Fee Schedule,61.65,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.63,166.65,
SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.,1000041,CDM,983,RC,11301,HCPCS,Outpatient,,,374,224.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.7,55,,,percent of total billed charges,55% of total billed charges,205.7,55,,,percent of total billed charges,55% of total billed charges,81.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.82,180,,,Fee Schedule,180% of CMS Fee Schedule,75.49,350,,,Fee Schedule,350% of CMS OPPS Rate,53.92,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.53,100,,,Fee Schedule,100% of Fee Schedule,81.42,100,,,Fee Schedule,100% of Fee Schedule,81.42,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,98.7,100,,,Fee Schedule,100% of UHC Fee Schedule,98.7,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.92,205.7,
SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1,1000042,CDM,983,RC,11302,HCPCS,Outpatient,,,441,264.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,242.55,55,,,percent of total billed charges,55% of total billed charges,242.55,55,,,percent of total billed charges,55% of total billed charges,95.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,101.81,180,,,Fee Schedule,180% of CMS Fee Schedule,88.9,350,,,Fee Schedule,350% of CMS OPPS Rate,63.5,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.32,100,,,Fee Schedule,100% of Fee Schedule,95.89,100,,,Fee Schedule,100% of Fee Schedule,95.89,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,64.98,100,,,Fee Schedule,100% of UHC Fee Schedule,64.98,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,242.55,
SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2,1000043,CDM,983,RC,11303,HCPCS,Outpatient,,,489,293.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,268.95,55,,,percent of total billed charges,55% of total billed charges,268.95,55,,,percent of total billed charges,55% of total billed charges,113.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,119.68,180,,,Fee Schedule,180% of CMS Fee Schedule,105.28,350,,,Fee Schedule,350% of CMS OPPS Rate,75.2,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,100,,,Fee Schedule,100% of Fee Schedule,113.55,100,,,Fee Schedule,100% of Fee Schedule,113.55,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,76.45,100,,,Fee Schedule,100% of UHC Fee Schedule,76.45,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.2,268.95,
SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5,1000044,CDM,983,RC,11305,HCPCS,Outpatient,,,308,184.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,169.4,55,,,percent of total billed charges,55% of total billed charges,169.4,55,,,percent of total billed charges,55% of total billed charges,60.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.35,180,,,Fee Schedule,180% of CMS Fee Schedule,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,39.85,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.35,100,,,Fee Schedule,100% of Fee Schedule,60.17,100,,,Fee Schedule,100% of Fee Schedule,60.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of UHC Fee Schedule,42.64,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.85,169.4,
SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6,1000045,CDM,983,RC,11306,HCPCS,Outpatient,,,381,228.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.55,55,,,percent of total billed charges,55% of total billed charges,209.55,55,,,percent of total billed charges,55% of total billed charges,79.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,96.84,180,,,Fee Schedule,180% of CMS Fee Schedule,73.89,350,,,Fee Schedule,350% of CMS OPPS Rate,52.78,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.65,100,,,Fee Schedule,100% of Fee Schedule,79.7,100,,,Fee Schedule,100% of Fee Schedule,79.7,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.99,100,,,Fee Schedule,100% of UHC Fee Schedule,61.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.78,209.55,
SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0,1000047,CDM,983,RC,11310,HCPCS,Outpatient,,,355,213,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.25,55,,,percent of total billed charges,55% of total billed charges,195.25,55,,,percent of total billed charges,55% of total billed charges,72.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.17,180,,,Fee Schedule,180% of CMS Fee Schedule,67.16,350,,,Fee Schedule,350% of CMS OPPS Rate,47.97,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.43,100,,,Fee Schedule,100% of Fee Schedule,72.43,100,,,Fee Schedule,100% of Fee Schedule,72.43,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,45.47,100,,,Fee Schedule,100% of UHC Fee Schedule,45.47,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.47,195.25,
SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-,1000048,CDM,983,RC,11311,HCPCS,Outpatient,,,388.68,233.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,213.77,55,,,percent of total billed charges,55% of total billed charges,213.77,55,,,percent of total billed charges,55% of total billed charges,100.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,103.54,180,,,Fee Schedule,180% of CMS Fee Schedule,92.76,350,,,Fee Schedule,350% of CMS OPPS Rate,66.26,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.92,100,,,Fee Schedule,100% of Fee Schedule,100.05,100,,,Fee Schedule,100% of Fee Schedule,100.05,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,66.13,100,,,Fee Schedule,100% of UHC Fee Schedule,66.13,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.13,213.77,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,1000051,CDM,983,RC,11401,HCPCS,Outpatient,,,782.95,469.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,430.62,55,,,percent of total billed charges,55% of total billed charges,430.62,55,,,percent of total billed charges,55% of total billed charges,155.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.05,180,,,Fee Schedule,180% of CMS Fee Schedule,144.1,350,,,Fee Schedule,350% of CMS OPPS Rate,102.93,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.55,100,,,Fee Schedule,100% of Fee Schedule,155.42,100,,,Fee Schedule,100% of Fee Schedule,155.42,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,184.23,100,,,Fee Schedule,100% of UHC Fee Schedule,184.23,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.93,430.62,
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2,1000052,CDM,983,RC,11402,HCPCS,Outpatient,,,526,315.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,289.3,55,,,percent of total billed charges,55% of total billed charges,289.3,55,,,percent of total billed charges,55% of total billed charges,171.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.78,180,,,Fee Schedule,180% of CMS Fee Schedule,159.12,350,,,Fee Schedule,350% of CMS OPPS Rate,113.66,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.79,100,,,Fee Schedule,100% of Fee Schedule,171.63,100,,,Fee Schedule,100% of Fee Schedule,171.63,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,209.19,100,,,Fee Schedule,100% of UHC Fee Schedule,209.19,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.66,289.3,
EXC B9 LESION MRGN XCP SK TG T/A/L 2.1-3,1000053,CDM,983,RC,11403,HCPCS,Outpatient,,,612,367.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,336.6,55,,,percent of total billed charges,55% of total billed charges,336.6,55,,,percent of total billed charges,55% of total billed charges,221.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,210.64,180,,,Fee Schedule,180% of CMS Fee Schedule,205.72,350,,,Fee Schedule,350% of CMS OPPS Rate,146.94,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.93,100,,,Fee Schedule,100% of Fee Schedule,221.89,100,,,Fee Schedule,100% of Fee Schedule,221.89,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,135.84,100,,,Fee Schedule,100% of UHC Fee Schedule,135.84,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.84,336.6,
EX BLSN INC MRGN EX S/N/H/F/G;DM<=.6-1CM,1000057,CDM,983,RC,11421,HCPCS,Outpatient,,,496,297.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,272.8,55,,,percent of total billed charges,55% of total billed charges,272.8,55,,,percent of total billed charges,55% of total billed charges,164.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,170.37,180,,,Fee Schedule,180% of CMS Fee Schedule,152.5,350,,,Fee Schedule,350% of CMS OPPS Rate,108.93,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.77,100,,,Fee Schedule,100% of Fee Schedule,164.48,100,,,Fee Schedule,100% of Fee Schedule,164.48,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,109.9,100,,,Fee Schedule,100% of UHC Fee Schedule,109.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.93,272.8,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,1000058,CDM,983,RC,11422,HCPCS,Outpatient,,,559,335.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,307.45,55,,,percent of total billed charges,55% of total billed charges,307.45,55,,,percent of total billed charges,55% of total billed charges,202.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,199.58,180,,,Fee Schedule,180% of CMS Fee Schedule,188.05,350,,,Fee Schedule,350% of CMS OPPS Rate,134.32,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.9,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,128.87,100,,,Fee Schedule,100% of UHC Fee Schedule,128.87,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.87,307.45,
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 3,1000060,CDM,960,RC,11424,HCPCS,Outpatient,,,746,447.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,410.3,55,,,percent of total billed charges,55% of total billed charges,410.3,55,,,percent of total billed charges,55% of total billed charges,271.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,276.25,180,,,Fee Schedule,180% of CMS Fee Schedule,251.52,350,,,Fee Schedule,350% of CMS OPPS Rate,179.66,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.29,100,,,Fee Schedule,100% of Fee Schedule,271.29,100,,,Fee Schedule,100% of Fee Schedule,271.29,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,178.14,100,,,Fee Schedule,100% of UHC Fee Schedule,178.14,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.14,410.3,
Separation and removal of the entire nail plate or a portion of nail plate,1000089,CDM,983,RC,11730,HCPCS,Outpatient,,,332,199.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.6,55,,,percent of total billed charges,55% of total billed charges,182.6,55,,,percent of total billed charges,55% of total billed charges,84.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,112.03,180,,,Fee Schedule,180% of CMS Fee Schedule,77.95,350,,,Fee Schedule,350% of CMS OPPS Rate,55.68,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.47,100,,,Fee Schedule,100% of Fee Schedule,84.08,100,,,Fee Schedule,100% of Fee Schedule,84.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of UHC Fee Schedule,72.14,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.68,182.6,
Injections to remove up to 7 lesions on the skin,1000098,CDM,960,RC,11900,HCPCS,Outpatient,,,177,106.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.35,55,,,percent of total billed charges,55% of total billed charges,97.35,55,,,percent of total billed charges,55% of total billed charges,47.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.03,180,,,Fee Schedule,180% of CMS Fee Schedule,44.34,350,,,Fee Schedule,350% of CMS OPPS Rate,31.67,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.52,100,,,Fee Schedule,100% of Fee Schedule,47.82,100,,,Fee Schedule,100% of Fee Schedule,47.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,31.24,100,,,Fee Schedule,100% of UHC Fee Schedule,31.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,97.35,
INSJ NON-BIODEGRADABLE DRUG DELIVERY IMP,1000101,CDM,960,RC,11981,HCPCS,Outpatient,,,453,271.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.15,55,,,percent of total billed charges,55% of total billed charges,249.15,55,,,percent of total billed charges,55% of total billed charges,129.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,148.9,180,,,Fee Schedule,180% of CMS Fee Schedule,119.94,350,,,Fee Schedule,350% of CMS OPPS Rate,85.67,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.8,100,,,Fee Schedule,100% of Fee Schedule,129.36,100,,,Fee Schedule,100% of Fee Schedule,129.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,95.5,100,,,Fee Schedule,100% of UHC Fee Schedule,95.5,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.67,279,
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY,1000102,CDM,960,RC,11982,HCPCS,Outpatient,,,509,305.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,279.95,55,,,percent of total billed charges,55% of total billed charges,279.95,55,,,percent of total billed charges,55% of total billed charges,154.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.64,180,,,Fee Schedule,180% of CMS Fee Schedule,143.32,350,,,Fee Schedule,350% of CMS OPPS Rate,102.37,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.58,100,,,Fee Schedule,100% of Fee Schedule,154.58,100,,,Fee Schedule,100% of Fee Schedule,154.58,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,116.72,100,,,Fee Schedule,100% of UHC Fee Schedule,116.72,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.37,313,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",1000104,CDM,983,RC,12001,HCPCS,Outpatient,,,286,171.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,157.3,55,,,percent of total billed charges,55% of total billed charges,157.3,55,,,percent of total billed charges,55% of total billed charges,68.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,171.27,180,,,Fee Schedule,180% of CMS Fee Schedule,63.36,350,,,Fee Schedule,350% of CMS OPPS Rate,45.26,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.04,100,,,Fee Schedule,100% of Fee Schedule,68.34,100,,,Fee Schedule,100% of Fee Schedule,68.34,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,148.41,100,,,Fee Schedule,100% of UHC Fee Schedule,148.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.26,171.27,
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6,1000106,CDM,983,RC,12004,HCPCS,Outpatient,,,411,246.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,226.05,55,,,percent of total billed charges,55% of total billed charges,226.05,55,,,percent of total billed charges,55% of total billed charges,112.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,226.31,180,,,Fee Schedule,180% of CMS Fee Schedule,104.73,350,,,Fee Schedule,350% of CMS OPPS Rate,74.81,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.36,100,,,Fee Schedule,100% of Fee Schedule,112.96,100,,,Fee Schedule,100% of Fee Schedule,112.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,145.35,100,,,Fee Schedule,100% of UHC Fee Schedule,145.35,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.81,243,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",1000109,CDM,983,RC,12011,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,55,,,percent of total billed charges,55% of total billed charges,192.5,55,,,percent of total billed charges,55% of total billed charges,84.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.67,180,,,Fee Schedule,180% of CMS Fee Schedule,78.57,350,,,Fee Schedule,350% of CMS OPPS Rate,56.12,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.81,100,,,Fee Schedule,100% of Fee Schedule,84.74,100,,,Fee Schedule,100% of Fee Schedule,84.74,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,161.12,100,,,Fee Schedule,100% of UHC Fee Schedule,161.12,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.12,192.5,
REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,1000114,CDM,983,RC,12034,HCPCS,Outpatient,,,991,594.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,545.05,55,,,percent of total billed charges,55% of total billed charges,545.05,55,,,percent of total billed charges,55% of total billed charges,313.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,301,180,,,Fee Schedule,180% of CMS Fee Schedule,290.91,350,,,Fee Schedule,350% of CMS OPPS Rate,207.79,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.77,100,,,Fee Schedule,100% of Fee Schedule,313.76,100,,,Fee Schedule,100% of Fee Schedule,313.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,193.28,100,,,Fee Schedule,100% of UHC Fee Schedule,193.28,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.28,545.05,
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5,1000118,CDM,983,RC,12041,HCPCS,Outpatient,,,748,448.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,411.4,55,,,percent of total billed charges,55% of total billed charges,411.4,55,,,percent of total billed charges,55% of total billed charges,225.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,240.66,180,,,Fee Schedule,180% of CMS Fee Schedule,208.68,350,,,Fee Schedule,350% of CMS OPPS Rate,149.06,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.44,100,,,Fee Schedule,100% of Fee Schedule,225.08,100,,,Fee Schedule,100% of Fee Schedule,225.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,154.38,100,,,Fee Schedule,100% of UHC Fee Schedule,154.38,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.06,411.4,
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 C,1000122,CDM,983,RC,12051,HCPCS,Outpatient,,,814,488.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,447.7,55,,,percent of total billed charges,55% of total billed charges,447.7,55,,,percent of total billed charges,55% of total billed charges,257.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,266.69,180,,,Fee Schedule,180% of CMS Fee Schedule,238.98,350,,,Fee Schedule,350% of CMS OPPS Rate,170.7,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.84,100,,,Fee Schedule,100% of Fee Schedule,257.76,100,,,Fee Schedule,100% of Fee Schedule,257.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,100% of UHC Fee Schedule,171.4,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.7,447.7,
Destruction of pre-cancerous lesion,1000190,CDM,960,RC,17000,HCPCS,Outpatient,,,208,124.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.4,55,,,percent of total billed charges,55% of total billed charges,114.4,55,,,percent of total billed charges,55% of total billed charges,78.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.29,180,,,Fee Schedule,180% of CMS Fee Schedule,73.21,350,,,Fee Schedule,350% of CMS OPPS Rate,52.29,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.16,100,,,Fee Schedule,100% of Fee Schedule,78.96,100,,,Fee Schedule,100% of Fee Schedule,78.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,92.24,100,,,Fee Schedule,100% of UHC Fee Schedule,92.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.29,114.4,
Destruction of 2-14 pre-cancerous lesions,1000191,CDM,960,RC,17003,HCPCS,Outpatient,,,17,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,9.35,55,,,percent of total billed charges,55% of total billed charges,9.35,55,,,percent of total billed charges,55% of total billed charges,3.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.99,180,,,Fee Schedule,180% of CMS Fee Schedule,3.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2.5,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,100,,,Fee Schedule,100% of Fee Schedule,3.79,100,,,Fee Schedule,100% of Fee Schedule,3.79,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,11.73,100,,,Fee Schedule,100% of UHC Fee Schedule,11.73,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,28,
Draining or injecting medication into a small joint/bursa without ultrasound,1000228,CDM,960,RC,20600,HCPCS,Outpatient,,,155,93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,103.67,100,,,Fee Schedule,pays at 100% of fee Schedule,103.67,100,,,Fee Schedule,pays at 100% of fee Schedule,55.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.01,180,,,Fee Schedule,180% of CMS Fee Schedule,51.11,350,,,Fee Schedule,350% of CMS OPPS Rate,36.51,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,100,,,Fee Schedule,100% of Fee Schedule,55.13,100,,,Fee Schedule,100% of Fee Schedule,55.13,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,90.24,100,,,Fee Schedule,100% of UHC Fee Schedule,90.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.51,103.67,
Draining or injecting medication into a major joint/bursa without ultrasound,1000232,CDM,983,RC,20610,HCPCS,Outpatient,,,195,117,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,137.62,100,,,Fee Schedule,pays at 100% of fee Schedule,137.62,100,,,Fee Schedule,pays at 100% of fee Schedule,70.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,86.09,180,,,Fee Schedule,180% of CMS Fee Schedule,65.46,350,,,Fee Schedule,350% of CMS OPPS Rate,46.76,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.86,100,,,Fee Schedule,100% of Fee Schedule,70.61,100,,,Fee Schedule,100% of Fee Schedule,70.61,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,111.68,100,,,Fee Schedule,100% of UHC Fee Schedule,111.68,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.76,137.62,
MNL PREP&INSJ I-ARTIC RX DEV,1000246,CDM,960,RC,20704,HCPCS,Outpatient,,,456,273.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.88,50,,,percent of total billed charges,pays at 50% of total billed charges,250.8,55,,,percent of total billed charges,55% of total billed charges,250.8,55,,,percent of total billed charges,55% of total billed charges,273.6,60,,,percent of total billed charges,pays at 60% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.6,60,,,percent of total billed charges,60% of total billed charges,273.6,60,,,percent of total billed charges,60% of total billed charges,273.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.23,100,,,Fee Schedule,100% of UHC Fee Schedule,150.23,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.88,273.6,
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,1000880,CDM,960,RC,30901,HCPCS,Outpatient,,,426,255.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,234.3,55,,,percent of total billed charges,55% of total billed charges,234.3,55,,,percent of total billed charges,55% of total billed charges,87.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,108.95,180,,,Fee Schedule,180% of CMS Fee Schedule,81.13,350,,,Fee Schedule,350% of CMS OPPS Rate,57.95,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.86,100,,,Fee Schedule,100% of Fee Schedule,87.5,60,,,percent of total billed charges,60% of total billed charges,87.5,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,103.89,100,,,Fee Schedule,100% of UHC Fee Schedule,103.89,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.95,234.3,
INTUBATION ENDOTRACHEAL EMERGENCY PROCED,1000901,CDM,983,RC,31500,HCPCS,Outpatient,,,478,286.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.53,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,262.9,55,,,percent of total billed charges,55% of total billed charges,262.9,55,,,percent of total billed charges,55% of total billed charges,221.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202.99,180,,,Fee Schedule,180% of CMS Fee Schedule,204.92,350,,,Fee Schedule,350% of CMS OPPS Rate,146.37,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.53,100,,,Fee Schedule,100% of Fee Schedule,221.02,100,,,Fee Schedule,100% of Fee Schedule,221.02,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,317.3,100,,,Fee Schedule,100% of UHC Fee Schedule,317.3,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.37,317.3,
INSERTION INTRA-AORTIC BALLOON ASSIST DE,1001036,CDM,983,RC,33967,HCPCS,Outpatient,,,895,537,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,492.25,55,,,percent of total billed charges,55% of total billed charges,492.25,55,,,percent of total billed charges,55% of total billed charges,413.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,462.31,180,,,Fee Schedule,180% of CMS Fee Schedule,383.25,350,,,Fee Schedule,350% of CMS OPPS Rate,273.75,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.09,100,,,Fee Schedule,100% of Fee Schedule,413.36,100,,,Fee Schedule,100% of Fee Schedule,413.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,405.18,100,,,Fee Schedule,100% of UHC Fee Schedule,405.18,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.75,539,
INSJ NONTUNNLD CENTRL VENS CATH AG;>=5,1001118,CDM,960,RC,36556,HCPCS,Outpatient,,,428.4,257.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,235.62,55,,,percent of total billed charges,55% of total billed charges,235.62,55,,,percent of total billed charges,55% of total billed charges,132.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,227,180,,,Fee Schedule,180% of CMS Fee Schedule,122.77,350,,,Fee Schedule,350% of CMS OPPS Rate,87.69,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.43,100,,,Fee Schedule,100% of Fee Schedule,132.41,100,,,Fee Schedule,100% of Fee Schedule,132.41,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,273.24,100,,,Fee Schedule,100% of UHC Fee Schedule,273.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.69,273.24,
ABDOM PARACENTESIS DX/THER W/IMAGING GUI,1001424,CDM,983,RC,49083,HCPCS,Outpatient,,,328.77,197.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.82,55,,,percent of total billed charges,55% of total billed charges,180.82,55,,,percent of total billed charges,55% of total billed charges,165.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,153.43,350,,,Fee Schedule,350% of CMS OPPS Rate,109.59,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.26,60,,,percent of total billed charges,60% of total billed charges,165.48,100,,,Fee Schedule,100% of Fee Schedule,165.48,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,374.48,100,,,Fee Schedule,100% of UHC Fee Schedule,374.48,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.59,374.48,
LAPS ABD PRTM&OMENTUM DX W/WO SPEC BR/WA,1001428,CDM,960,RC,49320,HCPCS,Outpatient,,,1094,656.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,601.7,55,,,percent of total billed charges,55% of total billed charges,601.7,55,,,percent of total billed charges,55% of total billed charges,504.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,546.66,180,,,Fee Schedule,180% of CMS Fee Schedule,468.02,350,,,Fee Schedule,350% of CMS OPPS Rate,334.3,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.69,100,,,Fee Schedule,100% of Fee Schedule,504.79,100,,,Fee Schedule,100% of Fee Schedule,504.79,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,467.54,100,,,Fee Schedule,100% of UHC Fee Schedule,467.54,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.3,680,
URTROLITHOTOMY UPPER ONE-THIRD URETER,1001470,CDM,983,RC,50610,HCPCS,Outpatient,,,3167,1900.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1670.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1741.85,55,,,percent of total billed charges,55% of total billed charges,1741.85,55,,,percent of total billed charges,55% of total billed charges,1453.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1591.11,180,,,Fee Schedule,180% of CMS Fee Schedule,1352.26,350,,,Fee Schedule,350% of CMS OPPS Rate,965.9,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.97,100,,,Fee Schedule,100% of Fee Schedule,1453.3,100,,,Fee Schedule,100% of Fee Schedule,1453.3,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,980.43,100,,,Fee Schedule,100% of UHC Fee Schedule,980.43,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,965.9,1968,
I&D VULVA/PERINEAL ABSCESS,1001582,CDM,983,RC,56405,HCPCS,Outpatient,,,351,210.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.05,55,,,percent of total billed charges,55% of total billed charges,193.05,55,,,percent of total billed charges,55% of total billed charges,167.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.36,180,,,Fee Schedule,180% of CMS Fee Schedule,155.6,350,,,Fee Schedule,350% of CMS OPPS Rate,111.14,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.49,100,,,Fee Schedule,100% of Fee Schedule,167.82,100,,,Fee Schedule,100% of Fee Schedule,167.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,110.27,100,,,Fee Schedule,100% of UHC Fee Schedule,110.27,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.27,193.05,
BIOPSY VULVA/PERINEUM 1 LESION SPX,1001588,CDM,960,RC,56605,HCPCS,Outpatient,,,264,158.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.2,55,,,percent of total billed charges,55% of total billed charges,145.2,55,,,percent of total billed charges,55% of total billed charges,91.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.99,180,,,Fee Schedule,180% of CMS Fee Schedule,85.01,350,,,Fee Schedule,350% of CMS OPPS Rate,60.72,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.99,100,,,Fee Schedule,100% of Fee Schedule,91.69,100,,,Fee Schedule,100% of Fee Schedule,91.69,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.72,145.2,
DESTRUCTION VAGINAL LESIONS SIMPLE,1001595,CDM,983,RC,57061,HCPCS,Outpatient,,,363,217.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,199.65,55,,,percent of total billed charges,55% of total billed charges,199.65,55,,,percent of total billed charges,55% of total billed charges,151.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,160.79,180,,,Fee Schedule,180% of CMS Fee Schedule,140.77,350,,,Fee Schedule,350% of CMS OPPS Rate,100.55,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.29,100,,,Fee Schedule,100% of Fee Schedule,151.83,100,,,Fee Schedule,100% of Fee Schedule,151.83,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,100.66,100,,,Fee Schedule,100% of UHC Fee Schedule,100.66,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.55,199.65,
BIOPSY VAGINAL MUCOSA SIMPLE,1001596,CDM,960,RC,57100,HCPCS,Outpatient,,,289,173.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,158.95,55,,,percent of total billed charges,55% of total billed charges,158.95,55,,,percent of total billed charges,55% of total billed charges,102.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,119.68,180,,,Fee Schedule,180% of CMS Fee Schedule,95.31,350,,,Fee Schedule,350% of CMS OPPS Rate,68.08,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.42,100,,,Fee Schedule,100% of Fee Schedule,102.8,100,,,Fee Schedule,100% of Fee Schedule,102.8,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,74.46,100,,,Fee Schedule,100% of UHC Fee Schedule,74.46,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.08,158.95,
EXCISION VAGINAL CYST/TUMOR,1001598,CDM,960,RC,57135,HCPCS,Outpatient,,,620,372,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,341,55,,,percent of total billed charges,55% of total billed charges,341,55,,,percent of total billed charges,55% of total billed charges,266.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,299.83,180,,,Fee Schedule,180% of CMS Fee Schedule,247.07,350,,,Fee Schedule,350% of CMS OPPS Rate,176.48,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.41,100,,,Fee Schedule,100% of Fee Schedule,266.48,100,,,Fee Schedule,100% of Fee Schedule,266.48,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,187.08,100,,,Fee Schedule,100% of UHC Fee Schedule,187.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.48,350,
COLPOSCOPY CERVIX UPPER/ADJACENT VAGINA,1001614,CDM,960,RC,57452,HCPCS,Outpatient,,,351,210.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.05,55,,,percent of total billed charges,55% of total billed charges,193.05,55,,,percent of total billed charges,55% of total billed charges,139.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,159.21,180,,,Fee Schedule,180% of CMS Fee Schedule,129.11,350,,,Fee Schedule,350% of CMS OPPS Rate,92.22,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.33,100,,,Fee Schedule,100% of Fee Schedule,139.25,100,,,Fee Schedule,100% of Fee Schedule,139.25,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,99.25,100,,,Fee Schedule,100% of UHC Fee Schedule,99.25,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.22,193.05,
Biopsy of cervix or uterus,1001615,CDM,960,RC,57454,HCPCS,Outpatient,,,492,295.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,270.6,55,,,percent of total billed charges,55% of total billed charges,270.6,55,,,percent of total billed charges,55% of total billed charges,202.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,245.59,180,,,Fee Schedule,180% of CMS Fee Schedule,188.05,350,,,Fee Schedule,350% of CMS OPPS Rate,134.32,102,,,Fee Schedule,102% of CMS OPPS Rate,194,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.47,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,153.06,100,,,Fee Schedule,100% of UHC Fee Schedule,153.06,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.32,270.6,
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C,1001616,CDM,960,RC,57455,HCPCS,Outpatient,,,459,275.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,252.45,55,,,percent of total billed charges,55% of total billed charges,252.45,55,,,percent of total billed charges,55% of total billed charges,167.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,203.33,180,,,Fee Schedule,180% of CMS Fee Schedule,154.91,350,,,Fee Schedule,350% of CMS OPPS Rate,110.65,102,,,Fee Schedule,102% of CMS OPPS Rate,299,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.42,100,,,Fee Schedule,100% of Fee Schedule,167.08,100,,,Fee Schedule,100% of Fee Schedule,167.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,126.63,100,,,Fee Schedule,100% of UHC Fee Schedule,126.63,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.65,299,
COLPOSCOPY CERVIX ENDOCERVICAL CURETTAGE,1001617,CDM,983,RC,57456,HCPCS,Outpatient,,,432,259.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,237.6,55,,,percent of total billed charges,55% of total billed charges,237.6,55,,,percent of total billed charges,55% of total billed charges,155.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.45,180,,,Fee Schedule,180% of CMS Fee Schedule,143.95,350,,,Fee Schedule,350% of CMS OPPS Rate,102.82,102,,,Fee Schedule,102% of CMS OPPS Rate,217,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.54,100,,,Fee Schedule,100% of Fee Schedule,155.26,100,,,Fee Schedule,100% of Fee Schedule,155.26,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,117.97,100,,,Fee Schedule,100% of UHC Fee Schedule,117.97,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.82,237.6,
Biopsy of the lining of the uterus,1001627,CDM,983,RC,58100,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,55,,,percent of total billed charges,55% of total billed charges,192.5,55,,,percent of total billed charges,55% of total billed charges,107.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,158.96,180,,,Fee Schedule,180% of CMS Fee Schedule,99.22,350,,,Fee Schedule,350% of CMS OPPS Rate,70.87,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.7,100,,,Fee Schedule,100% of Fee Schedule,107.01,100,,,Fee Schedule,100% of Fee Schedule,107.01,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,99.01,100,,,Fee Schedule,100% of UHC Fee Schedule,99.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.87,192.5,
INSERTION INTRAUTERINE DEVICE IUD,1001637,CDM,960,RC,58300,HCPCS,Outpatient,,,555,333,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,305.25,55,,,percent of total billed charges,55% of total billed charges,305.25,55,,,percent of total billed charges,55% of total billed charges,82.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.5,180,,,Fee Schedule,180% of CMS Fee Schedule,76.89,350,,,Fee Schedule,350% of CMS OPPS Rate,54.92,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333,60,,,percent of total billed charges,60% of total billed charges,82.93,100,,,Fee Schedule,100% of Fee Schedule,82.93,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.9,100,,,Fee Schedule,100% of UHC Fee Schedule,61.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.92,333,
REMOVAL INTRAUTERINE DEVICE IUD,1001638,CDM,960,RC,58301,HCPCS,Outpatient,,,305,183,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.75,55,,,percent of total billed charges,55% of total billed charges,167.75,55,,,percent of total billed charges,55% of total billed charges,102.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,125.19,180,,,Fee Schedule,180% of CMS Fee Schedule,95.07,350,,,Fee Schedule,350% of CMS OPPS Rate,67.91,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.11,100,,,Fee Schedule,100% of Fee Schedule,102.54,100,,,Fee Schedule,100% of Fee Schedule,102.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,77.87,100,,,Fee Schedule,100% of UHC Fee Schedule,77.87,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,167.75,
UTERINE SUSPENSION W/WO SHORTENING LIGAM,1001640,CDM,983,RC,58400,HCPCS,Outpatient,,,1434,860.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,788.7,55,,,percent of total billed charges,55% of total billed charges,788.7,55,,,percent of total billed charges,55% of total billed charges,671.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,714.94,180,,,Fee Schedule,180% of CMS Fee Schedule,622.15,350,,,Fee Schedule,350% of CMS OPPS Rate,444.39,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.27,100,,,Fee Schedule,100% of Fee Schedule,671.03,100,,,Fee Schedule,100% of Fee Schedule,671.03,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,446.18,100,,,Fee Schedule,100% of UHC Fee Schedule,446.18,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.39,882,
RMVL FB XTRNL AUDITORY CANAL W/O ANES,1001836,CDM,960,RC,69200,HCPCS,Outpatient,,,258,154.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,141.9,55,,,percent of total billed charges,55% of total billed charges,141.9,55,,,percent of total billed charges,55% of total billed charges,71.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.63,180,,,Fee Schedule,180% of CMS Fee Schedule,66.39,350,,,Fee Schedule,350% of CMS OPPS Rate,47.42,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.24,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,54.19,100,,,Fee Schedule,100% of UHC Fee Schedule,54.19,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.42,183.24,
Removal of ear wax from one or both ears,1001839,CDM,960,RC,69210,HCPCS,Outpatient,,,155,93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.25,55,,,percent of total billed charges,55% of total billed charges,85.25,55,,,percent of total billed charges,55% of total billed charges,50.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,58.5,180,,,Fee Schedule,180% of CMS Fee Schedule,46.65,350,,,Fee Schedule,350% of CMS OPPS Rate,33.32,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.24,100,,,Fee Schedule,100% of Fee Schedule,50.31,100,,,Fee Schedule,100% of Fee Schedule,50.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,63.92,100,,,Fee Schedule,100% of UHC Fee Schedule,63.92,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.32,85.25,
Eye exam on an established patient,1002471,CDM,962,RC,92012,HCPCS,Outpatient,,,273,163.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,150.15,55,,,percent of total billed charges,55% of total billed charges,150.15,55,,,percent of total billed charges,55% of total billed charges,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.9,180,,,Fee Schedule,180% of CMS Fee Schedule,72.56,350,,,Fee Schedule,350% of CMS OPPS Rate,51.83,102,,,Fee Schedule,102% of CMS OPPS Rate,91,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.93,100,,,Fee Schedule,100% of Fee Schedule,51.31,100,,,Fee Schedule,100% of Fee Schedule,51.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,30.17,100,,,Fee Schedule,100% of UHC Fee Schedule,30.17,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.17,150.15,
Eye exam and treatment for established patient,1002472,CDM,962,RC,92014,HCPCS,Outpatient,,,395,237,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,217.25,55,,,percent of total billed charges,55% of total billed charges,217.25,55,,,percent of total billed charges,55% of total billed charges,77.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.35,180,,,Fee Schedule,180% of CMS Fee Schedule,109.73,350,,,Fee Schedule,350% of CMS OPPS Rate,78.38,102,,,Fee Schedule,102% of CMS OPPS Rate,115,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.82,100,,,Fee Schedule,100% of Fee Schedule,77.6,100,,,Fee Schedule,100% of Fee Schedule,77.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,115.87,100,,,Fee Schedule,100% of UHC Fee Schedule,115.87,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.6,217.25,
CARDIOPULMONARY RESUSCITATION,1002490,CDM,983,RC,92950,HCPCS,Outpatient,,,970,582,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.08,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,533.5,55,,,percent of total billed charges,55% of total billed charges,533.5,55,,,percent of total billed charges,55% of total billed charges,189.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.78,180,,,Fee Schedule,180% of CMS Fee Schedule,267.9,350,,,Fee Schedule,350% of CMS OPPS Rate,191.36,102,,,Fee Schedule,102% of CMS OPPS Rate,442,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.3,100,,,Fee Schedule,100% of Fee Schedule,189.45,100,,,Fee Schedule,100% of Fee Schedule,189.45,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,338.39,100,,,Fee Schedule,100% of UHC Fee Schedule,338.39,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.45,533.5,
Routine EKG using at least 12 leads including interpretation and report,1002498,CDM,983,RC,93000,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,16.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.22,180,,,Fee Schedule,180% of CMS Fee Schedule,22.76,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,56,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.3,100,,,Fee Schedule,100% of Fee Schedule,16.1,100,,,Fee Schedule,100% of Fee Schedule,16.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,41.35,100,,,Fee Schedule,100% of UHC Fee Schedule,41.35,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,56,
ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY,1002499,CDM,983,RC,93005,HCPCS,Outpatient,,,26,15.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,14.3,55,,,percent of total billed charges,55% of total billed charges,14.3,55,,,percent of total billed charges,55% of total billed charges,7.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.43,180,,,Fee Schedule,180% of CMS Fee Schedule,10.89,350,,,Fee Schedule,350% of CMS OPPS Rate,7.78,102,,,Fee Schedule,102% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.4,100,,,Fee Schedule,100% of Fee Schedule,7.7,100,,,Fee Schedule,100% of Fee Schedule,7.7,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,24.35,100,,,Fee Schedule,100% of UHC Fee Schedule,24.35,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,33,
ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY,1002500,CDM,983,RC,93010,HCPCS,Outpatient,,,28,16.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,15.4,55,,,percent of total billed charges,55% of total billed charges,15.4,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,24,
Test to determine heart abnormalities,1002501,CDM,983,RC,93015,HCPCS,Outpatient,,,223,133.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.65,55,,,percent of total billed charges,55% of total billed charges,122.65,55,,,percent of total billed charges,55% of total billed charges,67.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.51,180,,,Fee Schedule,180% of CMS Fee Schedule,94.86,350,,,Fee Schedule,350% of CMS OPPS Rate,67.76,102,,,Fee Schedule,102% of CMS OPPS Rate,223,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.23,100,,,Fee Schedule,100% of Fee Schedule,67.08,100,,,Fee Schedule,100% of Fee Schedule,67.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,168.7,100,,,Fee Schedule,100% of UHC Fee Schedule,168.7,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.08,233,
CV STRS TST XERS&/OR RX CONT ECG W/O I&R,1002502,CDM,983,RC,93016,HCPCS,Outpatient,,,73,43.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.15,55,,,percent of total billed charges,55% of total billed charges,40.15,55,,,percent of total billed charges,55% of total billed charges,21.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.96,180,,,Fee Schedule,180% of CMS Fee Schedule,31.08,350,,,Fee Schedule,350% of CMS OPPS Rate,22.2,102,,,Fee Schedule,102% of CMS OPPS Rate,61,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.86,100,,,Fee Schedule,100% of Fee Schedule,21.98,100,,,Fee Schedule,100% of Fee Schedule,21.98,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,44.85,100,,,Fee Schedule,100% of UHC Fee Schedule,44.85,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.98,61,
CV STRS TST XERS&/OR RX CONT ECG TRCG ON,1002503,CDM,983,RC,93017,HCPCS,Outpatient,,,102,61.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.1,55,,,percent of total billed charges,55% of total billed charges,56.1,55,,,percent of total billed charges,55% of total billed charges,30.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.99,180,,,Fee Schedule,180% of CMS Fee Schedule,43.12,350,,,Fee Schedule,350% of CMS OPPS Rate,30.8,102,,,Fee Schedule,102% of CMS OPPS Rate,102,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102,100,,,Fee Schedule,100% of Fee Schedule,30.49,100,,,Fee Schedule,100% of Fee Schedule,30.49,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,94.28,100,,,Fee Schedule,100% of UHC Fee Schedule,94.28,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.49,122,
CV STRS TST XERS&/OR RX CONT ECG I&R ONL,1002504,CDM,983,RC,93018,HCPCS,Outpatient,,,48,28.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,26.4,55,,,percent of total billed charges,55% of total billed charges,26.4,55,,,percent of total billed charges,55% of total billed charges,14.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.54,180,,,Fee Schedule,180% of CMS Fee Schedule,20.66,350,,,Fee Schedule,350% of CMS OPPS Rate,14.76,102,,,Fee Schedule,102% of CMS OPPS Rate,48,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,100% of Fee Schedule,14.61,100,,,Fee Schedule,100% of Fee Schedule,14.61,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,29.57,100,,,Fee Schedule,100% of UHC Fee Schedule,29.57,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.61,50,
XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I,1002505,CDM,983,RC,93224,HCPCS,Outpatient,,,278,166.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.9,55,,,percent of total billed charges,55% of total billed charges,152.9,55,,,percent of total billed charges,55% of total billed charges,81.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,261.94,180,,,Fee Schedule,180% of CMS Fee Schedule,115.92,350,,,Fee Schedule,350% of CMS OPPS Rate,82.8,102,,,Fee Schedule,102% of CMS OPPS Rate,278,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.1,100,,,Fee Schedule,100% of Fee Schedule,81.97,100,,,Fee Schedule,100% of Fee Schedule,81.97,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,238.8,100,,,Fee Schedule,100% of UHC Fee Schedule,238.8,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.97,345,
XTRNL ECG & 48 HR RECORDING,1002506,CDM,983,RC,93225,HCPCS,Outpatient,,,79,47.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.45,55,,,percent of total billed charges,55% of total billed charges,43.45,55,,,percent of total billed charges,55% of total billed charges,23.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.42,180,,,Fee Schedule,180% of CMS Fee Schedule,32.83,350,,,Fee Schedule,350% of CMS OPPS Rate,23.45,102,,,Fee Schedule,102% of CMS OPPS Rate,79,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.21,100,,,Fee Schedule,100% of Fee Schedule,23.22,100,,,Fee Schedule,100% of Fee Schedule,23.22,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,70.13,100,,,Fee Schedule,100% of UHC Fee Schedule,70.13,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.22,90,
EXTERNAL ECG SCANNING ANALYSIS REPORT,1002507,CDM,983,RC,93226,HCPCS,Outpatient,,,112,67.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,55,,,percent of total billed charges,55% of total billed charges,61.6,55,,,percent of total billed charges,55% of total billed charges,32.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,136.64,180,,,Fee Schedule,180% of CMS Fee Schedule,46.26,350,,,Fee Schedule,350% of CMS OPPS Rate,33.04,102,,,Fee Schedule,102% of CMS OPPS Rate,112,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.61,100,,,Fee Schedule,100% of Fee Schedule,32.71,100,,,Fee Schedule,100% of Fee Schedule,32.71,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,88.6,100,,,Fee Schedule,100% of UHC Fee Schedule,88.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.71,159,
XTRNL ECG CONTINUOUS RHYTHM W/I&R UP TO,1002508,CDM,983,RC,93227,HCPCS,Outpatient,,,87,52.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.85,55,,,percent of total billed charges,55% of total billed charges,47.85,55,,,percent of total billed charges,55% of total billed charges,26.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.88,180,,,Fee Schedule,180% of CMS Fee Schedule,36.85,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,87,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.25,100,,,Fee Schedule,100% of Fee Schedule,26.06,100,,,Fee Schedule,100% of Fee Schedule,26.06,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,51.98,100,,,Fee Schedule,100% of UHC Fee Schedule,51.98,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.06,97,
XTRNL MOBILE CV TELEMETRY W/I&REPORT 30,1002509,CDM,983,RC,93228,HCPCS,Outpatient,,,86,51.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.3,55,,,percent of total billed charges,55% of total billed charges,47.3,55,,,percent of total billed charges,55% of total billed charges,25.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,36.55,350,,,Fee Schedule,350% of CMS OPPS Rate,26.11,102,,,Fee Schedule,102% of CMS OPPS Rate,52,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.32,100,,,Fee Schedule,100% of Fee Schedule,25.85,100,,,Fee Schedule,100% of Fee Schedule,25.85,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,26.69,100,,,Fee Schedule,100% of UHC Fee Schedule,26.69,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.85,52,
XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DA,1002510,CDM,983,RC,93272,HCPCS,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.65,55,,,percent of total billed charges,55% of total billed charges,45.65,55,,,percent of total billed charges,55% of total billed charges,25.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.88,180,,,Fee Schedule,180% of CMS Fee Schedule,35.5,350,,,Fee Schedule,350% of CMS OPPS Rate,25.36,102,,,Fee Schedule,102% of CMS OPPS Rate,68,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.4,100,,,Fee Schedule,100% of Fee Schedule,25.11,100,,,Fee Schedule,100% of Fee Schedule,25.11,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,29.61,100,,,Fee Schedule,100% of UHC Fee Schedule,29.61,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.11,68,
SIGNAL AVERAGED ELECTROCARDIOGRAPHY W/WO,1002511,CDM,983,RC,93278,HCPCS,Outpatient,,,96,57.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.8,55,,,percent of total billed charges,55% of total billed charges,52.8,55,,,percent of total billed charges,55% of total billed charges,28.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.92,180,,,Fee Schedule,180% of CMS Fee Schedule,40.67,350,,,Fee Schedule,350% of CMS OPPS Rate,29.05,102,,,Fee Schedule,102% of CMS OPPS Rate,96,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.03,100,,,Fee Schedule,100% of Fee Schedule,28.76,100,,,Fee Schedule,100% of Fee Schedule,28.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,63.03,100,,,Fee Schedule,100% of UHC Fee Schedule,63.03,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.76,161,
PROGRAM EVAL IMPLANTABLE IN PERSN DUAL L,1002513,CDM,960,RC,93280,HCPCS,Outpatient,,,186.24,111.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.43,55,,,percent of total billed charges,55% of total billed charges,102.43,55,,,percent of total billed charges,55% of total billed charges,61.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,86.91,350,,,Fee Schedule,350% of CMS OPPS Rate,62.08,102,,,Fee Schedule,102% of CMS OPPS Rate,115,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.65,100,,,Fee Schedule,100% of Fee Schedule,61.46,100,,,Fee Schedule,100% of Fee Schedule,61.46,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,82.4,100,,,Fee Schedule,100% of UHC Fee Schedule,82.4,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.46,119.65,
PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1,1002515,CDM,960,RC,93282,HCPCS,Outpatient,,,194,116.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.7,55,,,percent of total billed charges,55% of total billed charges,106.7,55,,,percent of total billed charges,55% of total billed charges,64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,90.51,350,,,Fee Schedule,350% of CMS OPPS Rate,64.65,102,,,Fee Schedule,102% of CMS OPPS Rate,123,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.64,100,,,Fee Schedule,100% of Fee Schedule,64,100,,,Fee Schedule,100% of Fee Schedule,64,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.41,129.64,
INTERROGATION EVAL IN PERSON 1/DUAL/MLT,1002518,CDM,960,RC,93288,HCPCS,Outpatient,,,126.15,75.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.38,55,,,percent of total billed charges,55% of total billed charges,69.38,55,,,percent of total billed charges,55% of total billed charges,41.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,58.87,350,,,Fee Schedule,350% of CMS OPPS Rate,42.05,102,,,Fee Schedule,102% of CMS OPPS Rate,74,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.84,100,,,Fee Schedule,100% of Fee Schedule,41.63,100,,,Fee Schedule,100% of Fee Schedule,41.63,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,60.93,100,,,Fee Schedule,100% of UHC Fee Schedule,60.93,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.63,77.84,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",1002527,CDM,960,RC,93306,HCPCS,Outpatient,,,644,386.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,354.2,55,,,percent of total billed charges,55% of total billed charges,354.2,55,,,percent of total billed charges,55% of total billed charges,191.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,271.01,350,,,Fee Schedule,350% of CMS OPPS Rate,193.58,102,,,Fee Schedule,102% of CMS OPPS Rate,390,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.7,100,,,Fee Schedule,100% of Fee Schedule,191.64,100,,,Fee Schedule,100% of Fee Schedule,191.64,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,284.72,100,,,Fee Schedule,100% of UHC Fee Schedule,284.72,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.64,469.7,
INTRACUTANEOUS TESTS W/ALLERGENIC EXTRAC,1002581,CDM,960,RC,95024,HCPCS,Outpatient,,,25,15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,13.75,55,,,percent of total billed charges,55% of total billed charges,13.75,55,,,percent of total billed charges,55% of total billed charges,1.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.38,180,,,Fee Schedule,180% of CMS Fee Schedule,10.51,350,,,Fee Schedule,350% of CMS OPPS Rate,7.51,102,,,Fee Schedule,102% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,100,,,Fee Schedule,100% of Fee Schedule,1.1,100,,,Fee Schedule,100% of Fee Schedule,1.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,6.96,100,,,Fee Schedule,100% of UHC Fee Schedule,6.96,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,13.75,
PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTI,1002583,CDM,960,RC,95165,HCPCS,Outpatient,,,40,24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22,55,,,percent of total billed charges,55% of total billed charges,22,55,,,percent of total billed charges,55% of total billed charges,3.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.96,180,,,Fee Schedule,180% of CMS Fee Schedule,18.4,350,,,Fee Schedule,350% of CMS OPPS Rate,13.14,102,,,Fee Schedule,102% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.28,100,,,Fee Schedule,100% of Fee Schedule,3.2,100,,,Fee Schedule,100% of Fee Schedule,3.2,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,6.46,100,,,Fee Schedule,100% of UHC Fee Schedule,6.46,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,22,
THERAPEUTIC PROPHYLACTIC/DX INJECTION SU,1002596,CDM,960,RC,96372,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,15.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,22.16,350,,,Fee Schedule,350% of CMS OPPS Rate,15.83,102,,,Fee Schedule,102% of CMS OPPS Rate,50,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.28,100,,,Fee Schedule,100% of Fee Schedule,15.67,100,,,Fee Schedule,100% of Fee Schedule,15.67,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,26.9,100,,,Fee Schedule,100% of UHC Fee Schedule,26.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,50,
OFFICE OUTPATIENT NEW 10 MINUTES,1002621,CDM,983,RC,99201,HCPCS,Outpatient,,,140,84,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of fee Schedule,26.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.3,180,,,Fee Schedule,180% of CMS Fee Schedule,37.53,350,,,Fee Schedule,350% of CMS OPPS Rate,26.81,102,,,Fee Schedule,102% of CMS OPPS Rate,56,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.13,100,,,Fee Schedule,100% of Fee Schedule,26.54,100,,,Fee Schedule,100% of Fee Schedule,26.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.02,100,,,Fee Schedule,100% of UHC Fee Schedule,27.02,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,56,
"New patient office or other outpatient visit, typically 10 minutes",1002622,CDM,983,RC,99202,HCPCS,Outpatient,,,237,142.2,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.22,100,,,Fee Schedule,pays at 100% of fee Schedule,68.22,100,,,Fee Schedule,pays at 100% of fee Schedule,49.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.42,180,,,Fee Schedule,180% of CMS Fee Schedule,70.56,350,,,Fee Schedule,350% of CMS OPPS Rate,50.4,102,,,Fee Schedule,102% of CMS OPPS Rate,89,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.77,100,,,Fee Schedule,100% of Fee Schedule,49.9,100,,,Fee Schedule,100% of Fee Schedule,49.9,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,53.02,100,,,Fee Schedule,100% of UHC Fee Schedule,53.02,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,89,
"New patient office or other outpatient visit, typically 30 min",1002623,CDM,983,RC,99203,HCPCS,Outpatient,,,344,206.4,,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,101.6,100,,,Fee Schedule,pays at 100% of fee Schedule,101.6,100,,,Fee Schedule,pays at 100% of fee Schedule,75.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.71,180,,,Fee Schedule,180% of CMS Fee Schedule,106.53,350,,,Fee Schedule,350% of CMS OPPS Rate,76.09,102,,,Fee Schedule,102% of CMS OPPS Rate,122,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.43,100,,,Fee Schedule,100% of Fee Schedule,75.33,100,,,Fee Schedule,100% of Fee Schedule,75.33,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,81.81,100,,,Fee Schedule,100% of UHC Fee Schedule,81.81,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,122,
"New patient office of other outpatient visit, typically 45 min",1002624,CDM,960,RC,99204,HCPCS,Outpatient,,,527,316.2,,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.92,100,,,Fee Schedule,pays at 100% of fee Schedule,143.92,100,,,Fee Schedule,pays at 100% of fee Schedule,127.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,144.75,180,,,Fee Schedule,180% of CMS Fee Schedule,180.07,350,,,Fee Schedule,350% of CMS OPPS Rate,128.62,102,,,Fee Schedule,102% of CMS OPPS Rate,182,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.52,100,,,Fee Schedule,100% of Fee Schedule,127.33,100,,,Fee Schedule,100% of Fee Schedule,127.33,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,121.07,100,,,Fee Schedule,100% of UHC Fee Schedule,121.07,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,182,
"New patient office of other outpatient visit, typically 60 min",1002625,CDM,983,RC,99205,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.38,100,,,Fee Schedule,pays at 100% of fee Schedule,183.38,100,,,Fee Schedule,pays at 100% of fee Schedule,166.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,192.77,180,,,Fee Schedule,180% of CMS Fee Schedule,234.91,350,,,Fee Schedule,350% of CMS OPPS Rate,167.79,102,,,Fee Schedule,102% of CMS OPPS Rate,229,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.3,100,,,Fee Schedule,100% of Fee Schedule,166.11,100,,,Fee Schedule,100% of Fee Schedule,166.11,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,161.14,100,,,Fee Schedule,100% of UHC Fee Schedule,161.14,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,234.91,
Outpatient visit of established patient not requiring a physician,1002626,CDM,983,RC,99211,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,21.74,100,,,Fee Schedule,pays at 100% of fee Schedule,21.74,100,,,Fee Schedule,pays at 100% of fee Schedule,9.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.26,180,,,Fee Schedule,180% of CMS Fee Schedule,12.82,350,,,Fee Schedule,350% of CMS OPPS Rate,9.16,102,,,Fee Schedule,102% of CMS OPPS Rate,27,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.15,100,,,Fee Schedule,100% of Fee Schedule,9.07,100,,,Fee Schedule,100% of Fee Schedule,9.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,10.26,100,,,Fee Schedule,100% of UHC Fee Schedule,10.26,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,27,
Outpatient visit of established patient requiring a physician,1002627,CDM,983,RC,99212,HCPCS,Outpatient,,,138,82.8,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.36,100,,,Fee Schedule,pays at 100% of fee Schedule,39.36,100,,,Fee Schedule,pays at 100% of fee Schedule,25.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.75,180,,,Fee Schedule,180% of CMS Fee Schedule,35.59,350,,,Fee Schedule,350% of CMS OPPS Rate,25.42,102,,,Fee Schedule,102% of CMS OPPS Rate,48,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.49,100,,,Fee Schedule,100% of Fee Schedule,25.17,100,,,Fee Schedule,100% of Fee Schedule,25.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.17,48,
"Established patient office or other outpatient visit, typically 15 minutes",1002628,CDM,983,RC,99213,HCPCS,Outpatient,,,231,138.6,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.27,100,,,Fee Schedule,pays at 100% of fee Schedule,55.27,100,,,Fee Schedule,pays at 100% of fee Schedule,50.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.01,180,,,Fee Schedule,180% of CMS Fee Schedule,71.08,350,,,Fee Schedule,350% of CMS OPPS Rate,50.77,102,,,Fee Schedule,102% of CMS OPPS Rate,68,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.74,100,,,Fee Schedule,100% of Fee Schedule,50.26,100,,,Fee Schedule,100% of Fee Schedule,50.26,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,40.07,100,,,Fee Schedule,100% of UHC Fee Schedule,40.07,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,71.08,
"Established patient office or other outpatient visit, typically 25 minutes",1002629,CDM,983,RC,99214,HCPCS,Outpatient,,,342,205.2,,,,,,Other,Not Separately reimbursable,33.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.43,100,,,Fee Schedule,pays at 100% of fee Schedule,86.43,100,,,Fee Schedule,pays at 100% of fee Schedule,77.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,79.59,180,,,Fee Schedule,180% of CMS Fee Schedule,109.48,350,,,Fee Schedule,350% of CMS OPPS Rate,78.2,102,,,Fee Schedule,102% of CMS OPPS Rate,105,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.19,100,,,Fee Schedule,100% of Fee Schedule,77.42,100,,,Fee Schedule,100% of Fee Schedule,77.42,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,66.46,100,,,Fee Schedule,100% of UHC Fee Schedule,66.46,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,109.48,
"Established patient office or other outpatient, visit typically 40 minutes",1002630,CDM,983,RC,99215,HCPCS,Outpatient,,,463,277.8,,,,,,Other,Not Separately reimbursable,55.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.34,100,,,Fee Schedule,pays at 100% of fee Schedule,126.34,100,,,Fee Schedule,pays at 100% of fee Schedule,109.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,127.61,180,,,Fee Schedule,180% of CMS Fee Schedule,154.48,350,,,Fee Schedule,350% of CMS OPPS Rate,110.34,102,,,Fee Schedule,102% of CMS OPPS Rate,166,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.54,100,,,Fee Schedule,100% of Fee Schedule,109.24,100,,,Fee Schedule,100% of Fee Schedule,109.24,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,106.53,100,,,Fee Schedule,100% of UHC Fee Schedule,106.53,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,166,
OBSERVATION CARE DISCHARGE MANAGEMENT,1002631,CDM,987,RC,99217,HCPCS,Outpatient,,,237,142.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.09,180,,,Fee Schedule,180% of CMS Fee Schedule,100.91,350,,,Fee Schedule,350% of CMS OPPS Rate,72.08,102,,,Fee Schedule,102% of CMS OPPS Rate,131,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.17,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,140.76,100,,,Fee Schedule,100% of UHC Fee Schedule,140.76,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,140.76,
INITIAL OBSERVATION CARE/DAY 30 MINUTES,1002632,CDM,987,RC,99218,HCPCS,Outpatient,,,328,196.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,98.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.04,180,,,Fee Schedule,180% of CMS Fee Schedule,139.22,350,,,Fee Schedule,350% of CMS OPPS Rate,99.44,102,,,Fee Schedule,102% of CMS OPPS Rate,129,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,160.51,100,,,Fee Schedule,100% of UHC Fee Schedule,160.51,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,160.51,
INITIAL OBSERVATION CARE/DAY 50 MINUTES,1002633,CDM,987,RC,99219,HCPCS,Outpatient,,,445,267,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,133.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,151.51,180,,,Fee Schedule,180% of CMS Fee Schedule,189.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.16,102,,,Fee Schedule,102% of CMS OPPS Rate,205,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,241.31,100,,,Fee Schedule,100% of UHC Fee Schedule,241.31,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,241.31,
INITIAL OBSERVATION CARE/DAY 70 MINUTES,1002634,CDM,987,RC,99220,HCPCS,Outpatient,,,608,364.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,182.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.77,180,,,Fee Schedule,180% of CMS Fee Schedule,258.29,350,,,Fee Schedule,350% of CMS OPPS Rate,184.49,102,,,Fee Schedule,102% of CMS OPPS Rate,258,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,334.41,100,,,Fee Schedule,100% of UHC Fee Schedule,334.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,334.41,
INITIAL HOSPITAL CARE/DAY 30 MINUTES,1002635,CDM,987,RC,99221,HCPCS,Outpatient,,,333,199.8,,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,100.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,92.06,180,,,Fee Schedule,180% of CMS Fee Schedule,141.93,350,,,Fee Schedule,350% of CMS OPPS Rate,101.38,102,,,Fee Schedule,102% of CMS OPPS Rate,127,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.98,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,163.1,100,,,Fee Schedule,100% of UHC Fee Schedule,163.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,163.1,
INITIAL HOSPITAL CARE/DAY 50 MINUTES,1002636,CDM,987,RC,99222,HCPCS,Outpatient,,,448,268.8,,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,135.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,152.4,180,,,Fee Schedule,180% of CMS Fee Schedule,190.93,350,,,Fee Schedule,350% of CMS OPPS Rate,136.38,102,,,Fee Schedule,102% of CMS OPPS Rate,210,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.21,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,243.12,100,,,Fee Schedule,100% of UHC Fee Schedule,243.12,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,243.12,
INITIAL HOSPITAL CARE/DAY 70 MINUTES,1002637,CDM,987,RC,99223,HCPCS,Outpatient,,,663,397.8,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,199.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.21,180,,,Fee Schedule,180% of CMS Fee Schedule,281.51,350,,,Fee Schedule,350% of CMS OPPS Rate,201.08,102,,,Fee Schedule,102% of CMS OPPS Rate,268,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.79,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,347.96,100,,,Fee Schedule,100% of UHC Fee Schedule,347.96,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,347.96,
SBSQ OBSERVATION CARE/DAY 15 MINUTES,1002638,CDM,987,RC,99224,HCPCS,Outpatient,,,131,78.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,39.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,55.4,350,,,Fee Schedule,350% of CMS OPPS Rate,39.57,102,,,Fee Schedule,102% of CMS OPPS Rate,81,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.6,60,,,percent of total billed charges,60% of total billed charges,39.17,100,,,Fee Schedule,100% of Fee Schedule,39.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,72.76,100,,,Fee Schedule,100% of UHC Fee Schedule,72.76,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,81,
SBSQ OBSERVATION CARE/DAY 25 MINUTES,1002639,CDM,987,RC,99225,HCPCS,Outpatient,,,238,142.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,71.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,101.7,350,,,Fee Schedule,350% of CMS OPPS Rate,72.64,102,,,Fee Schedule,102% of CMS OPPS Rate,146,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.8,60,,,percent of total billed charges,60% of total billed charges,71.91,100,,,Fee Schedule,100% of Fee Schedule,71.91,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,133.1,100,,,Fee Schedule,100% of UHC Fee Schedule,133.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.38,146,
SBSQ OBSERVATION CARE/DAY 35 MINUTES,1002640,CDM,987,RC,99226,HCPCS,Outpatient,,,342,205.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,102.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,145.47,350,,,Fee Schedule,350% of CMS OPPS Rate,103.91,102,,,Fee Schedule,102% of CMS OPPS Rate,210,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.2,60,,,percent of total billed charges,60% of total billed charges,102.87,100,,,Fee Schedule,100% of Fee Schedule,102.87,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,191.01,100,,,Fee Schedule,100% of UHC Fee Schedule,191.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.43,210,
SBSQ HOSPITAL CARE/DAY 15 MINUTES,1002641,CDM,987,RC,99231,HCPCS,Outpatient,,,129,77.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,38.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.98,180,,,Fee Schedule,180% of CMS Fee Schedule,54.95,350,,,Fee Schedule,350% of CMS OPPS Rate,39.25,102,,,Fee Schedule,102% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,71.74,100,,,Fee Schedule,100% of UHC Fee Schedule,71.74,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.02,71.74,
SBSQ HOSPITAL CARE/DAY 25 MINUTES,1002642,CDM,987,RC,99232,HCPCS,Outpatient,,,238,142.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,71.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.11,180,,,Fee Schedule,180% of CMS Fee Schedule,101.23,350,,,Fee Schedule,350% of CMS OPPS Rate,72.31,102,,,Fee Schedule,102% of CMS OPPS Rate,97,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.72,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.08,100,,,Fee Schedule,100% of UHC Fee Schedule,124.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.57,124.08,
SBSQ HOSPITAL CARE/DAY 35 MINUTES,1002643,CDM,987,RC,99233,HCPCS,Outpatient,,,341,204.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,102.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.85,180,,,Fee Schedule,180% of CMS Fee Schedule,144.73,350,,,Fee Schedule,350% of CMS OPPS Rate,103.38,102,,,Fee Schedule,102% of CMS OPPS Rate,135,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,176.95,100,,,Fee Schedule,100% of UHC Fee Schedule,176.95,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.74,176.95,
OBSERVATION/INPATIENT HOSPITAL CARE 40 M,1002644,CDM,987,RC,99234,HCPCS,Outpatient,,,436,261.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,131.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.11,180,,,Fee Schedule,180% of CMS Fee Schedule,185.57,350,,,Fee Schedule,350% of CMS OPPS Rate,132.55,102,,,Fee Schedule,102% of CMS OPPS Rate,240,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.04,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,265.6,100,,,Fee Schedule,100% of UHC Fee Schedule,265.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.22,265.6,
OBSERVATION/INPATIENT HOSPITAL CARE 50 M,1002645,CDM,987,RC,99235,HCPCS,Outpatient,,,553,331.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,166.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,241.57,180,,,Fee Schedule,180% of CMS Fee Schedule,235.56,350,,,Fee Schedule,350% of CMS OPPS Rate,168.26,102,,,Fee Schedule,102% of CMS OPPS Rate,327,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.19,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,344.61,100,,,Fee Schedule,100% of UHC Fee Schedule,344.61,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.58,344.61,
OBSERVATION/INPATIENT HOSPITAL CARE 55 M,1002646,CDM,987,RC,99236,HCPCS,Outpatient,,,713,427.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,214.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,301.39,180,,,Fee Schedule,180% of CMS Fee Schedule,302.69,350,,,Fee Schedule,350% of CMS OPPS Rate,216.21,102,,,Fee Schedule,102% of CMS OPPS Rate,398,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.08,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,435.21,100,,,Fee Schedule,100% of UHC Fee Schedule,435.21,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.05,435.21,
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MIN,1002647,CDM,987,RC,99238,HCPCS,Outpatient,,,237,142.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.98,180,,,Fee Schedule,180% of CMS Fee Schedule,100.91,350,,,Fee Schedule,350% of CMS OPPS Rate,72.08,102,,,Fee Schedule,102% of CMS OPPS Rate,131,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.79,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,140.59,100,,,Fee Schedule,100% of UHC Fee Schedule,140.59,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,140.59,
HOSPITAL DISCHARGE DAY MANAGEMENT > 30 M,1002648,CDM,987,RC,99239,HCPCS,Outpatient,,,349,209.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,104.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,129.57,180,,,Fee Schedule,180% of CMS Fee Schedule,147.88,350,,,Fee Schedule,350% of CMS OPPS Rate,105.63,102,,,Fee Schedule,102% of CMS OPPS Rate,166,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.75,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,198.01,100,,,Fee Schedule,100% of UHC Fee Schedule,198.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.78,198.01,
"Patient office consultation, typically 40 min",1002651,CDM,983,RC,99243,HCPCS,Outpatient,,,450,270,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.85,100,,,Fee Schedule,pays at 100% of fee Schedule,127.85,100,,,Fee Schedule,pays at 100% of fee Schedule,94.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.85,180,,,Fee Schedule,180% of CMS Fee Schedule,133.28,350,,,Fee Schedule,350% of CMS OPPS Rate,95.2,102,,,Fee Schedule,102% of CMS OPPS Rate,180,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.94,100,,,Fee Schedule,100% of Fee Schedule,94.25,100,,,Fee Schedule,100% of Fee Schedule,94.25,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,106.36,100,,,Fee Schedule,100% of UHC Fee Schedule,106.36,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,180,
"Patient office consultation, typically 60 min",1002652,CDM,983,RC,99244,HCPCS,Outpatient,,,547,328.2,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,181.6,100,,,Fee Schedule,pays at 100% of fee Schedule,181.6,100,,,Fee Schedule,pays at 100% of fee Schedule,151.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.21,180,,,Fee Schedule,180% of CMS Fee Schedule,214.28,350,,,Fee Schedule,350% of CMS OPPS Rate,153.06,102,,,Fee Schedule,102% of CMS OPPS Rate,252,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.96,100,,,Fee Schedule,100% of Fee Schedule,151.53,100,,,Fee Schedule,100% of Fee Schedule,151.53,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,156.62,100,,,Fee Schedule,100% of UHC Fee Schedule,156.62,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,252,
OFFICE CONSULT LEVEL V,1002653,CDM,983,RC,99245,HCPCS,Outpatient,,,668,400.8,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,234.8,100,,,Fee Schedule,pays at 100% of fee Schedule,234.8,100,,,Fee Schedule,pays at 100% of fee Schedule,187.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,248.96,180,,,Fee Schedule,180% of CMS Fee Schedule,265.29,350,,,Fee Schedule,350% of CMS OPPS Rate,189.49,102,,,Fee Schedule,102% of CMS OPPS Rate,341,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.21,100,,,Fee Schedule,100% of Fee Schedule,187.6,100,,,Fee Schedule,100% of Fee Schedule,187.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,208.3,100,,,Fee Schedule,100% of UHC Fee Schedule,208.3,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,341,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 2,1002655,CDM,988,RC,99251,HCPCS,Outpatient,,,158,94.8,,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,48.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.61,180,,,Fee Schedule,180% of CMS Fee Schedule,68.4,350,,,Fee Schedule,350% of CMS OPPS Rate,48.86,102,,,Fee Schedule,102% of CMS OPPS Rate,92,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.2,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,40.75,100,,,Fee Schedule,100% of UHC Fee Schedule,40.75,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,92,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 4,1002656,CDM,988,RC,99252,HCPCS,Outpatient,,,215,129,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.85,100,,,Fee Schedule,pays at 100% of fee Schedule,77.85,100,,,Fee Schedule,pays at 100% of fee Schedule,73.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.55,180,,,Fee Schedule,180% of CMS Fee Schedule,104.38,350,,,Fee Schedule,350% of CMS OPPS Rate,74.56,102,,,Fee Schedule,102% of CMS OPPS Rate,140,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.59,100,,,Fee Schedule,100% of Fee Schedule,73.82,100,,,Fee Schedule,100% of Fee Schedule,73.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,145.1,100,,,Fee Schedule,100% of UHC Fee Schedule,145.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,145.1,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 5,1002657,CDM,988,RC,99253,HCPCS,Outpatient,,,290,174,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,113.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,133.29,180,,,Fee Schedule,180% of CMS Fee Schedule,160.59,350,,,Fee Schedule,350% of CMS OPPS Rate,114.71,102,,,Fee Schedule,102% of CMS OPPS Rate,185,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.57,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,209.03,100,,,Fee Schedule,100% of UHC Fee Schedule,209.03,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,209.03,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 8,1002658,CDM,988,RC,99254,HCPCS,Outpatient,,,420,252,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.21,100,,,Fee Schedule,pays at 100% of fee Schedule,152.21,100,,,Fee Schedule,pays at 100% of fee Schedule,164.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,191.39,180,,,Fee Schedule,180% of CMS Fee Schedule,233.14,350,,,Fee Schedule,350% of CMS OPPS Rate,166.53,102,,,Fee Schedule,102% of CMS OPPS Rate,254,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.07,100,,,Fee Schedule,100% of Fee Schedule,164.86,100,,,Fee Schedule,100% of Fee Schedule,164.86,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,301.45,100,,,Fee Schedule,100% of UHC Fee Schedule,301.45,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,301.45,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 1,1002659,CDM,988,RC,99255,HCPCS,Outpatient,,,575,345,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,198.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.89,180,,,Fee Schedule,180% of CMS Fee Schedule,280.78,350,,,Fee Schedule,350% of CMS OPPS Rate,200.56,102,,,Fee Schedule,102% of CMS OPPS Rate,343,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.17,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,390.94,100,,,Fee Schedule,100% of UHC Fee Schedule,390.94,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,390.94,
CRITICAL CARE ILL/INJURED PATIENT INIT 3,1002665,CDM,983,RC,99291,HCPCS,Outpatient,,,886,531.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280.99,180,,,Fee Schedule,180% of CMS Fee Schedule,312.84,350,,,Fee Schedule,350% of CMS OPPS Rate,223.46,102,,,Fee Schedule,102% of CMS OPPS Rate,392,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.12,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,424.54,100,,,Fee Schedule,100% of UHC Fee Schedule,424.54,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221,424.54,
CRITICAL CARE ILL/INJURED PATIENT ADDL 3,1002666,CDM,983,RC,99292,HCPCS,Outpatient,,,401,240.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.49,100,,,Fee Schedule,pays at 100% of fee Schedule,110.49,100,,,Fee Schedule,pays at 100% of fee Schedule,110.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,141.04,180,,,Fee Schedule,180% of CMS Fee Schedule,156.95,350,,,Fee Schedule,350% of CMS OPPS Rate,112.11,102,,,Fee Schedule,102% of CMS OPPS Rate,191,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.47,100,,,Fee Schedule,100% of Fee Schedule,110.99,100,,,Fee Schedule,100% of Fee Schedule,110.99,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,213.08,100,,,Fee Schedule,100% of UHC Fee Schedule,213.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.49,213.08,
SBSQ NURSING FACIL CARE/DAY MINOR COMPLJ,1002671,CDM,960,RC,99308,HCPCS,Outpatient,,,224,134.4,,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,66.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.52,180,,,Fee Schedule,180% of CMS Fee Schedule,94.7,350,,,Fee Schedule,350% of CMS OPPS Rate,67.64,102,,,Fee Schedule,102% of CMS OPPS Rate,140,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.23,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,120.61,100,,,Fee Schedule,100% of UHC Fee Schedule,120.61,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.97,140,
SBSQ NURSING FACIL CARE/DAY NEW PROBLEM,1002672,CDM,960,RC,99309,HCPCS,Outpatient,,,296,177.6,,,,,,Other,Not Separately reimbursable,85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.61,100,,,Fee Schedule,pays at 100% of fee Schedule,84.61,100,,,Fee Schedule,pays at 100% of fee Schedule,89.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.57,180,,,Fee Schedule,180% of CMS Fee Schedule,126.03,350,,,Fee Schedule,350% of CMS OPPS Rate,90.02,102,,,Fee Schedule,102% of CMS OPPS Rate,184,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.64,100,,,Fee Schedule,100% of Fee Schedule,89.12,100,,,Fee Schedule,100% of Fee Schedule,89.12,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,165.59,100,,,Fee Schedule,100% of UHC Fee Schedule,165.59,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.61,184,
SBSQ NURS FACIL CARE/DAY UNSTABL/NEW PRO,1002673,CDM,960,RC,99310,HCPCS,Outpatient,,,440,264,,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105.96,100,,,Fee Schedule,pays at 100% of fee Schedule,105.96,100,,,Fee Schedule,pays at 100% of fee Schedule,132.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,133.45,180,,,Fee Schedule,180% of CMS Fee Schedule,186.86,350,,,Fee Schedule,350% of CMS OPPS Rate,133.47,102,,,Fee Schedule,102% of CMS OPPS Rate,273,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.04,100,,,Fee Schedule,100% of Fee Schedule,132.15,100,,,Fee Schedule,100% of Fee Schedule,132.15,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,225.05,100,,,Fee Schedule,100% of UHC Fee Schedule,225.05,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.96,273,
PROLONGED SERVICE I/P REQ UNIT/FLOOR TIM,1002690,CDM,983,RC,99356,HCPCS,Outpatient,,,300,180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.19,100,,,Fee Schedule,pays at 100% of fee Schedule,97.19,100,,,Fee Schedule,pays at 100% of fee Schedule,90.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,122.51,180,,,Fee Schedule,180% of CMS Fee Schedule,127.83,350,,,Fee Schedule,350% of CMS OPPS Rate,91.31,102,,,Fee Schedule,102% of CMS OPPS Rate,182,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.81,100,,,Fee Schedule,100% of Fee Schedule,90.4,100,,,Fee Schedule,100% of Fee Schedule,90.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,179.82,100,,,Fee Schedule,100% of UHC Fee Schedule,179.82,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.4,182,
PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA,1002691,CDM,983,RC,99357,HCPCS,Outpatient,,,301,180.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.55,100,,,Fee Schedule,pays at 100% of fee Schedule,97.55,100,,,Fee Schedule,pays at 100% of fee Schedule,90.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.52,180,,,Fee Schedule,180% of CMS Fee Schedule,128.28,350,,,Fee Schedule,350% of CMS OPPS Rate,91.63,102,,,Fee Schedule,102% of CMS OPPS Rate,183,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,100,,,Fee Schedule,100% of Fee Schedule,90.71,100,,,Fee Schedule,100% of Fee Schedule,90.71,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,103.15,100,,,Fee Schedule,100% of UHC Fee Schedule,103.15,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.71,183,
PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE,1002692,CDM,960,RC,99358,HCPCS,Outpatient,,,364,218.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,156.07,100,,,Fee Schedule,pays at 100% of fee Schedule,156.07,100,,,Fee Schedule,pays at 100% of fee Schedule,109.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,155.3,350,,,Fee Schedule,350% of CMS OPPS Rate,110.93,102,,,Fee Schedule,102% of CMS OPPS Rate,190,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,60,,,percent of total billed charges,60% of total billed charges,109.82,100,,,Fee Schedule,100% of Fee Schedule,109.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,94.29,100,,,Fee Schedule,100% of UHC Fee Schedule,94.29,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.29,218.4,
New preventative visit in new patients 12-17 years old,1002697,CDM,983,RC,99384,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,100.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.05,180,,,Fee Schedule,180% of CMS Fee Schedule,142.18,350,,,Fee Schedule,350% of CMS OPPS Rate,101.56,102,,,Fee Schedule,102% of CMS OPPS Rate,206,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,100.54,100,,,Fee Schedule,100% of Fee Schedule,100.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,141.34,100,,,Fee Schedule,100% of UHC Fee Schedule,141.34,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,399,
Initial new patient preventive medicine evaluation (18?9 years),1002698,CDM,983,RC,99385,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,96.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.05,180,,,Fee Schedule,180% of CMS Fee Schedule,136.19,350,,,Fee Schedule,350% of CMS OPPS Rate,97.28,102,,,Fee Schedule,102% of CMS OPPS Rate,198,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,96.31,100,,,Fee Schedule,100% of Fee Schedule,96.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,137.7,100,,,Fee Schedule,100% of UHC Fee Schedule,137.7,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.35,399,
Initial new patient preventive medicine evaluation (40?4 years),1002699,CDM,983,RC,99386,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.04,100,,,Fee Schedule,pays at 100% of fee Schedule,145.04,100,,,Fee Schedule,pays at 100% of fee Schedule,117.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,136.02,180,,,Fee Schedule,180% of CMS Fee Schedule,165.86,350,,,Fee Schedule,350% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of CMS OPPS Rate,240,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,117.29,100,,,Fee Schedule,100% of Fee Schedule,117.29,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,168.06,100,,,Fee Schedule,100% of UHC Fee Schedule,168.06,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.39,399,
Initial visit for new patients 65 and older years old,1002700,CDM,983,RC,99387,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,157.3,100,,,Fee Schedule,pays at 100% of fee Schedule,157.3,100,,,Fee Schedule,pays at 100% of fee Schedule,126,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,148.72,180,,,Fee Schedule,180% of CMS Fee Schedule,178.18,350,,,Fee Schedule,350% of CMS OPPS Rate,127.27,102,,,Fee Schedule,102% of CMS OPPS Rate,258,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,126,100,,,Fee Schedule,100% of Fee Schedule,126,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,181.8,100,,,Fee Schedule,100% of UHC Fee Schedule,181.8,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.41,399,
Periodic primary re-evaluation for an established infant patient,1002701,CDM,983,RC,99391,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.55,100,,,Fee Schedule,pays at 100% of fee Schedule,81.55,100,,,Fee Schedule,pays at 100% of fee Schedule,69.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.88,180,,,Fee Schedule,180% of CMS Fee Schedule,97.68,350,,,Fee Schedule,350% of CMS OPPS Rate,69.77,102,,,Fee Schedule,102% of CMS OPPS Rate,147,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,69.07,100,,,Fee Schedule,100% of Fee Schedule,69.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of UHC Fee Schedule,95.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.02,210,
New preventative visit in new patients 12-17 years old,1002704,CDM,983,RC,99394,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.21,100,,,Fee Schedule,pays at 100% of fee Schedule,100.21,100,,,Fee Schedule,pays at 100% of fee Schedule,85.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.32,180,,,Fee Schedule,180% of CMS Fee Schedule,121.37,350,,,Fee Schedule,350% of CMS OPPS Rate,86.69,102,,,Fee Schedule,102% of CMS OPPS Rate,174,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,85.82,100,,,Fee Schedule,100% of Fee Schedule,85.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,122.38,100,,,Fee Schedule,100% of UHC Fee Schedule,122.38,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.72,210,
Established patient periodic preventive medicine examination age 18-39 years,1002705,CDM,983,RC,99395,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,101.3,100,,,Fee Schedule,pays at 100% of fee Schedule,101.3,100,,,Fee Schedule,pays at 100% of fee Schedule,88.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.32,180,,,Fee Schedule,180% of CMS Fee Schedule,124.78,350,,,Fee Schedule,350% of CMS OPPS Rate,89.13,102,,,Fee Schedule,102% of CMS OPPS Rate,179,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,88.24,100,,,Fee Schedule,100% of Fee Schedule,88.24,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.45,100,,,Fee Schedule,100% of UHC Fee Schedule,124.45,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.03,210,
Established patient periodic preventive medicine examination age 40-64 years,1002706,CDM,983,RC,99396,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,112.13,100,,,Fee Schedule,pays at 100% of fee Schedule,112.13,100,,,Fee Schedule,pays at 100% of fee Schedule,95.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.05,180,,,Fee Schedule,180% of CMS Fee Schedule,135.18,350,,,Fee Schedule,350% of CMS OPPS Rate,96.56,102,,,Fee Schedule,102% of CMS OPPS Rate,255,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,95.59,100,,,Fee Schedule,100% of Fee Schedule,95.59,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,137.09,100,,,Fee Schedule,100% of UHC Fee Schedule,137.09,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.36,255,
Periodic primary re-evaluation for an established patient 65 and older,1002707,CDM,983,RC,99397,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.66,100,,,Fee Schedule,pays at 100% of fee Schedule,123.66,100,,,Fee Schedule,pays at 100% of fee Schedule,100.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.75,180,,,Fee Schedule,180% of CMS Fee Schedule,142.18,350,,,Fee Schedule,350% of CMS OPPS Rate,101.56,102,,,Fee Schedule,102% of CMS OPPS Rate,206,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,100.54,100,,,Fee Schedule,100% of Fee Schedule,100.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,147.6,100,,,Fee Schedule,100% of UHC Fee Schedule,147.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,210,
PREVENTIVE MEDICINE COUNSELING;  30 MIN,1002708,CDM,983,RC,99402,HCPCS,Outpatient,,,200.31,120.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.53,100,,,Fee Schedule,pays at 100% of fee Schedule,73.53,100,,,Fee Schedule,pays at 100% of fee Schedule,49.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,69.73,180,,,Fee Schedule,180% of CMS Fee Schedule,70.08,350,,,Fee Schedule,350% of CMS OPPS Rate,50.06,102,,,Fee Schedule,102% of CMS OPPS Rate,101,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.19,60,,,percent of total billed charges,60% of total billed charges,49.56,100,,,Fee Schedule,100% of Fee Schedule,49.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,77,100,,,Fee Schedule,100% of UHC Fee Schedule,77,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.56,120.19,
TOBACCO USE CESSATION INTERMEDIATE 3-10,1002709,CDM,983,RC,99406,HCPCS,Outpatient,,,47,28.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of fee Schedule,12.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,17.35,350,,,Fee Schedule,350% of CMS OPPS Rate,12.39,102,,,Fee Schedule,102% of CMS OPPS Rate,25,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.58,100,,,Fee Schedule,100% of Fee Schedule,12.27,100,,,Fee Schedule,100% of Fee Schedule,12.27,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,25.32,100,,,Fee Schedule,100% of UHC Fee Schedule,25.32,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,25.32,
TOBACCO USE CESSATION INTENSIVE >10 MINU,1002710,CDM,983,RC,99407,HCPCS,Outpatient,,,91,54.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.39,100,,,Fee Schedule,pays at 100% of fee Schedule,25.39,100,,,Fee Schedule,pays at 100% of fee Schedule,25.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,36.15,350,,,Fee Schedule,350% of CMS OPPS Rate,25.82,102,,,Fee Schedule,102% of CMS OPPS Rate,52,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,100,,,Fee Schedule,100% of Fee Schedule,25.56,100,,,Fee Schedule,100% of Fee Schedule,25.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,50.47,100,,,Fee Schedule,100% of UHC Fee Schedule,50.47,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,52,
ALCOHOL/SUBSTANCE SCREEN & INTERVENTION,1002711,CDM,983,RC,99409,HCPCS,Outpatient,,,214.38,128.63,,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.38,100,,,Fee Schedule,pays at 100% of fee Schedule,61.38,100,,,Fee Schedule,pays at 100% of fee Schedule,65.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,92.81,350,,,Fee Schedule,350% of CMS OPPS Rate,66.29,102,,,Fee Schedule,102% of CMS OPPS Rate,134,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.63,60,,,percent of total billed charges,60% of total billed charges,65.63,100,,,Fee Schedule,100% of Fee Schedule,65.63,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,134,
"Physician telephone patient service, 11-20 minutes of medical discussion",1002714,CDM,960,RC,99442,HCPCS,Outpatient,,,228.45,137.07,,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,24.38,100,,,Fee Schedule,pays at 100% of fee Schedule,24.38,100,,,Fee Schedule,pays at 100% of fee Schedule,25.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,35.55,350,,,Fee Schedule,350% of CMS OPPS Rate,25.39,102,,,Fee Schedule,102% of CMS OPPS Rate,51,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.07,60,,,percent of total billed charges,60% of total billed charges,25.14,100,,,Fee Schedule,100% of Fee Schedule,25.14,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.25,100,,,Fee Schedule,100% of UHC Fee Schedule,27.25,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,137.07,
"Physician telephone patient service, 21-30 minutes of medical discussion",1002715,CDM,960,RC,99443,HCPCS,Outpatient,,,331.29,198.77,,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.21,100,,,Fee Schedule,pays at 100% of fee Schedule,36.21,100,,,Fee Schedule,pays at 100% of fee Schedule,37.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,53.24,350,,,Fee Schedule,350% of CMS OPPS Rate,38.03,102,,,Fee Schedule,102% of CMS OPPS Rate,77,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.77,60,,,percent of total billed charges,60% of total billed charges,37.65,100,,,Fee Schedule,100% of Fee Schedule,37.65,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,39.73,100,,,Fee Schedule,100% of UHC Fee Schedule,39.73,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25,198.77,
ADVANCE CARE PLANNING FIRST 30 MINS,1002728,CDM,983,RC,99497,HCPCS,Outpatient,,,274,164.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,50,,,percent of total billed charges,pays at 50% of total billed charges,150.7,55,,,percent of total billed charges,55% of total billed charges,150.7,55,,,percent of total billed charges,55% of total billed charges,77.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,109.93,350,,,Fee Schedule,350% of CMS OPPS Rate,78.52,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.4,60,,,percent of total billed charges,60% of total billed charges,77.73,100,,,Fee Schedule,100% of Fee Schedule,77.73,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,83.18,100,,,Fee Schedule,100% of UHC Fee Schedule,83.18,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,164.4,
ADVANCE CARE PLANNING EA ADDL 30 MINS,1002729,CDM,983,RC,99498,HCPCS,Outpatient,,,243,145.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.89,50,,,percent of total billed charges,pays at 50% of total billed charges,133.65,55,,,percent of total billed charges,55% of total billed charges,133.65,55,,,percent of total billed charges,55% of total billed charges,73.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,103.38,350,,,Fee Schedule,350% of CMS OPPS Rate,73.84,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.8,60,,,percent of total billed charges,60% of total billed charges,73.1,100,,,Fee Schedule,100% of Fee Schedule,73.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,73.3,100,,,Fee Schedule,100% of UHC Fee Schedule,73.3,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.89,145.8,
EXT ECG > 48HR TO 21 DAY RCRD W/CONECT I,1002731,CDM,983,RC,0296T,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,21.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,25.83,350,,,Fee Schedule,350% of CMS OPPS Rate,18.45,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,60,,,percent of total billed charges,60% of total billed charges,21.31,100,,,Fee Schedule,100% of Fee Schedule,21.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,43.18,
EXT ECG > 48HR TO 21 DAY REVIEW AND INTE,1002732,CDM,983,RC,0298T,HCPCS,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.65,55,,,percent of total billed charges,55% of total billed charges,45.65,55,,,percent of total billed charges,55% of total billed charges,26.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,35.73,350,,,Fee Schedule,350% of CMS OPPS Rate,25.52,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.8,60,,,percent of total billed charges,60% of total billed charges,26.06,100,,,Fee Schedule,100% of Fee Schedule,26.06,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.52,49.8,
CERVIX/VAGINAL CA SCREEN,1002757,CDM,971,RC,G0101,HCPCS,Outpatient,,,121,72.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.55,55,,,percent of total billed charges,55% of total billed charges,66.55,55,,,percent of total billed charges,55% of total billed charges,27.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.96,180,,,Fee Schedule,180% of CMS Fee Schedule,52.58,350,,,Fee Schedule,350% of CMS OPPS Rate,37.56,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,100% of Fee Schedule,27.06,100,,,Fee Schedule,100% of Fee Schedule,27.06,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.81,100,,,Fee Schedule,100% of UHC Fee Schedule,61.81,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,66.55,
TRIMMING OF DYSTROPHIC NAIL(S),1002763,CDM,983,RC,G0127,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.25,55,,,percent of total billed charges,55% of total billed charges,41.25,55,,,percent of total billed charges,55% of total billed charges,7.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.36,180,,,Fee Schedule,180% of CMS Fee Schedule,10.98,350,,,Fee Schedule,350% of CMS OPPS Rate,7.84,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.44,100,,,Fee Schedule,100% of Fee Schedule,7.76,100,,,Fee Schedule,100% of Fee Schedule,7.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,100% of UHC Fee Schedule,22.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,41.25,
INITIAL PREVENTIVE PHYSICAL EXAMINATION,1002770,CDM,983,RC,G0402,HCPCS,Outpatient,,,532,319.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,292.6,55,,,percent of total billed charges,55% of total billed charges,292.6,55,,,percent of total billed charges,55% of total billed charges,124.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,176.43,350,,,Fee Schedule,350% of CMS OPPS Rate,126.02,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.66,100,,,Fee Schedule,100% of Fee Schedule,124.76,100,,,Fee Schedule,100% of Fee Schedule,124.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,265.96,100,,,Fee Schedule,100% of UHC Fee Schedule,265.96,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.76,292.6,
ANNUAL WELLNESS VISIT;  INITIAL VISIT,1002776,CDM,983,RC,G0438,HCPCS,Outpatient,,,548,328.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,301.4,55,,,percent of total billed charges,55% of total billed charges,301.4,55,,,percent of total billed charges,55% of total billed charges,164.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,232.97,350,,,Fee Schedule,350% of CMS OPPS Rate,166.41,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.8,60,,,percent of total billed charges,60% of total billed charges,164.75,100,,,Fee Schedule,100% of Fee Schedule,164.75,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,304.09,100,,,Fee Schedule,100% of UHC Fee Schedule,304.09,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,328.8,
ANNUAL WELLNESS VISIT  SUBSEQUENT VISIT,1002777,CDM,983,RC,G0439,HCPCS,Outpatient,,,370,222,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.5,55,,,percent of total billed charges,55% of total billed charges,203.5,55,,,percent of total billed charges,55% of total billed charges,110.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,156.91,350,,,Fee Schedule,350% of CMS OPPS Rate,112.08,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222,60,,,percent of total billed charges,60% of total billed charges,110.96,100,,,Fee Schedule,100% of Fee Schedule,110.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,205.1,100,,,Fee Schedule,100% of UHC Fee Schedule,205.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.68,222,
OBTAINING SCREEN PAP SMEAR; PREP/CONVY T,1002870,CDM,960,RC,Q0091,HCPCS,Outpatient,,,138,82.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.9,55,,,percent of total billed charges,55% of total billed charges,75.9,55,,,percent of total billed charges,55% of total billed charges,19.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.76,180,,,Fee Schedule,180% of CMS Fee Schedule,57.79,350,,,Fee Schedule,350% of CMS OPPS Rate,41.28,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.58,100,,,Fee Schedule,100% of Fee Schedule,19.34,100,,,Fee Schedule,100% of Fee Schedule,19.34,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,29.08,100,,,Fee Schedule,100% of UHC Fee Schedule,29.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.34,75.9,
"CGM PROFESSIONAL ANALYSIS, INTERP AND RP",1003000,CDM,960,RC,95251,HCPCS,Outpatient,,,107,64.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.85,55,,,percent of total billed charges,55% of total billed charges,58.85,55,,,percent of total billed charges,55% of total billed charges,35.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.88,180,,,Fee Schedule,180% of CMS Fee Schedule,49.83,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,89,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.23,100,,,Fee Schedule,100% of Fee Schedule,35.23,100,,,Fee Schedule,100% of Fee Schedule,35.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,25.07,100,,,Fee Schedule,100% of UHC Fee Schedule,25.07,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,89,
EKG INTERPRET AND REPORT,3788030E,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
EKG INTERPRET AND REPORT,3788060E,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
EKG INTERPRET AND REPORT,4111101,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
EKG INTERPRET AND REPORT,4111102,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
INITIAL HOSPITAL CARE PER DAY,7960001,CDM,985,RC,99221,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,100.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.98,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,127,
INITIAL HOSPITAL CARE PER DAY,7960002,CDM,985,RC,99222,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,135.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.21,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,210,
INITIAL HOSPITAL CARE PER DAY,7960003,CDM,985,RC,99223,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,199.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.79,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,268,
SUBSEQUENT HOSPITAL CARE PER DAY,7960004,CDM,985,RC,99231,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,38.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.02,66,
SUBSEQUENT HOSPITAL CARE PER DAY,7960005,CDM,985,RC,99232,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,71.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.72,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.57,97,
SUBSEQUENT HOSPITAL CARE PER DAY,7960006,CDM,985,RC,99233,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,102.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.74,135,
DISCHARGE HOSPITAL CARE < 30 MINUTES,7960007,CDM,985,RC,99238,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.79,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,131,
DISCHARGE HOSPITAL CARE > 30 MINUTES,7960008,CDM,985,RC,99239,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,104.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.75,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.78,166,
OBSV HOSPITAL CARE A&D SAME DAY,7960009,CDM,985,RC,99234,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,131.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.04,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.22,240,
OBSV HOSPITAL CARE A&D SAME DAY,7960010,CDM,985,RC,99235,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,166.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.19,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.58,327,
OBSV HOSPITAL CARE A&D SAME DAY,7960011,CDM,985,RC,99236,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,214.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.08,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.05,398,
OBSERVATION INITIAL HOSPITAL CARE,7960012,CDM,985,RC,99218,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,98.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,129,
OBSERVATION INITIAL HOSPITAL CARE,7960013,CDM,985,RC,99219,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,133.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,205,
OBSERVATION INITIAL HOSPITAL CARE,7960014,CDM,985,RC,99220,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,182.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,258,
OBSERVATION DISCHARGE HOSPITAL CARE,7960015,CDM,985,RC,99217,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.17,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,131,
OBSV SUBSEQUENT HOSPITAL CARE PER DAY,7960016,CDM,985,RC,99224,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,39.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.17,100,,,Fee Schedule,100% of Fee Schedule,39.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,81,
OBSV SUBSEQUENT HOSPITAL CARE PER DAY,7960017,CDM,985,RC,99225,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,71.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,100,,,Fee Schedule,100% of Fee Schedule,71.91,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.38,146,
OBSV SUBSEQUENT HOSPITAL CARE PER DAY,7960018,CDM,985,RC,99226,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,102.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.87,100,,,Fee Schedule,100% of Fee Schedule,102.87,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.43,210,
"Emergency department visit, moderately severe problem",7960019,CDM,985,RC,99283,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,165,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,67.59,100,,,Fee Schedule,pays at 100% of fee Schedule,67.59,100,,,Fee Schedule,pays at 100% of fee Schedule,62.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.66,100,,,Fee Schedule,100% of Fee Schedule,62.12,100,,,Fee Schedule,100% of Fee Schedule,62.12,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.12,165,
INPATIENT HOSPITAL CONSULT BRIEF,7960020,CDM,985,RC,99251,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,48.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.2,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,92,
INPATIENT HOSPITAL CONSULT COMPREHENSIVE,7960021,CDM,985,RC,99255,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,198.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.17,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,343,
INPATIENT HOSPITAL CONSULT INTERMEDIATE,7960022,CDM,985,RC,99253,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,113.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.57,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,185,
HOSPITAL CRITICAL CARE EVAL,7960023,CDM,985,RC,99291,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.12,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221,392,
SUBSEQUENT NURSING HOME HOSPITAL CARE,7960024,CDM,985,RC,99308,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,66.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.23,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.97,140,
Incision and drainage of abscess; simple or single and complex or multiple,1000005,CDM,983,RC,10060,HCPCS,Outpatient,,,375,225,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,206.25,55,,,percent of total billed charges,55% of total billed charges,206.25,55,,,percent of total billed charges,55% of total billed charges,145.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,142.2,180,,,Fee Schedule,180% of CMS Fee Schedule,134.76,350,,,Fee Schedule,350% of CMS OPPS Rate,96.26,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.15,100,,,Fee Schedule,100% of Fee Schedule,145.35,100,,,Fee Schedule,100% of Fee Schedule,145.35,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,173.65,100,,,Fee Schedule,100% of UHC Fee Schedule,173.65,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.26,206.25,
INCISION&DRAINAGE ABSCESS COMPLICATED/MU,1000006,CDM,983,RC,10061,HCPCS,Outpatient,,,658,394.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,361.9,55,,,percent of total billed charges,55% of total billed charges,361.9,55,,,percent of total billed charges,55% of total billed charges,269.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,269.14,180,,,Fee Schedule,180% of CMS Fee Schedule,249.62,350,,,Fee Schedule,350% of CMS OPPS Rate,178.3,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.83,100,,,Fee Schedule,100% of Fee Schedule,269.23,100,,,Fee Schedule,100% of Fee Schedule,269.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,325.15,100,,,Fee Schedule,100% of UHC Fee Schedule,325.15,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.3,361.9,
INCISION&REMOVAL FOREIGN BODY SUBQ TISS,1000009,CDM,983,RC,10120,HCPCS,Outpatient,,,480,288,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,264,55,,,percent of total billed charges,55% of total billed charges,264,55,,,percent of total billed charges,55% of total billed charges,152.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,147.92,180,,,Fee Schedule,180% of CMS Fee Schedule,141.62,350,,,Fee Schedule,350% of CMS OPPS Rate,101.16,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.87,100,,,Fee Schedule,100% of Fee Schedule,152.75,100,,,Fee Schedule,100% of Fee Schedule,152.75,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,181.48,100,,,Fee Schedule,100% of UHC Fee Schedule,181.48,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.16,264,
"Incision and drainage of hematoma, seroma or fluid collection",1000011,CDM,983,RC,10140,HCPCS,Outpatient,,,519,311.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,285.45,55,,,percent of total billed charges,55% of total billed charges,285.45,55,,,percent of total billed charges,55% of total billed charges,177.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,192.6,180,,,Fee Schedule,180% of CMS Fee Schedule,164.32,350,,,Fee Schedule,350% of CMS OPPS Rate,117.37,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.72,100,,,Fee Schedule,100% of Fee Schedule,177.23,100,,,Fee Schedule,100% of Fee Schedule,177.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.71,100,,,Fee Schedule,100% of UHC Fee Schedule,124.71,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.37,285.45,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",1000034,CDM,983,RC,11102,HCPCS,Outpatient,,,279.63,167.78,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,153.8,55,,,percent of total billed charges,55% of total billed charges,153.8,55,,,percent of total billed charges,55% of total billed charges,60.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,56.2,350,,,Fee Schedule,350% of CMS OPPS Rate,40.14,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.78,60,,,percent of total billed charges,60% of total billed charges,60.61,100,,,Fee Schedule,100% of Fee Schedule,60.61,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,93.6,100,,,Fee Schedule,100% of UHC Fee Schedule,93.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.14,167.78,
PUNCH BIOPSY OF THE SKIN,1000036,CDM,983,RC,11104,HCPCS,Outpatient,,,351.42,210.85,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.28,55,,,percent of total billed charges,55% of total billed charges,193.28,55,,,percent of total billed charges,55% of total billed charges,76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,70.46,350,,,Fee Schedule,350% of CMS OPPS Rate,50.33,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.85,60,,,percent of total billed charges,60% of total billed charges,76,100,,,Fee Schedule,100% of Fee Schedule,76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,117.52,100,,,Fee Schedule,100% of UHC Fee Schedule,117.52,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.33,210.85,
PUNCH BIOPSY OF SKIN INCLUDING SIMPLE CL,1000037,CDM,983,RC,11105,HCPCS,Outpatient,,,175,105,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,96.25,55,,,percent of total billed charges,55% of total billed charges,96.25,55,,,percent of total billed charges,55% of total billed charges,41.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,38.42,350,,,Fee Schedule,350% of CMS OPPS Rate,27.44,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,60,,,percent of total billed charges,60% of total billed charges,41.43,100,,,Fee Schedule,100% of Fee Schedule,41.43,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,56.89,100,,,Fee Schedule,100% of UHC Fee Schedule,56.89,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.44,105,
"Removal of skin tags, multiple fibrocutaneous tags, any area",1000038,CDM,983,RC,11200,HCPCS,Outpatient,,,282,169.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,155.1,55,,,percent of total billed charges,55% of total billed charges,155.1,55,,,percent of total billed charges,55% of total billed charges,108.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.32,180,,,Fee Schedule,180% of CMS Fee Schedule,100.23,350,,,Fee Schedule,350% of CMS OPPS Rate,71.59,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.06,100,,,Fee Schedule,100% of Fee Schedule,108.1,100,,,Fee Schedule,100% of Fee Schedule,108.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.81,100,,,Fee Schedule,100% of UHC Fee Schedule,124.81,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.59,155.1,
SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM,1000040,CDM,983,RC,11300,HCPCS,Outpatient,,,303,181.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.47,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,166.65,55,,,percent of total billed charges,55% of total billed charges,166.65,55,,,percent of total billed charges,55% of total billed charges,53.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.09,180,,,Fee Schedule,180% of CMS Fee Schedule,49.88,350,,,Fee Schedule,350% of CMS OPPS Rate,35.63,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.71,100,,,Fee Schedule,100% of Fee Schedule,53.8,100,,,Fee Schedule,100% of Fee Schedule,53.8,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.65,100,,,Fee Schedule,100% of UHC Fee Schedule,61.65,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.63,166.65,
SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.,1000041,CDM,983,RC,11301,HCPCS,Outpatient,,,374,224.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,205.7,55,,,percent of total billed charges,55% of total billed charges,205.7,55,,,percent of total billed charges,55% of total billed charges,81.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,82.82,180,,,Fee Schedule,180% of CMS Fee Schedule,75.49,350,,,Fee Schedule,350% of CMS OPPS Rate,53.92,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.53,100,,,Fee Schedule,100% of Fee Schedule,81.42,100,,,Fee Schedule,100% of Fee Schedule,81.42,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,98.7,100,,,Fee Schedule,100% of UHC Fee Schedule,98.7,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.92,205.7,
SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1,1000042,CDM,983,RC,11302,HCPCS,Outpatient,,,441,264.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,242.55,55,,,percent of total billed charges,55% of total billed charges,242.55,55,,,percent of total billed charges,55% of total billed charges,95.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,101.81,180,,,Fee Schedule,180% of CMS Fee Schedule,88.9,350,,,Fee Schedule,350% of CMS OPPS Rate,63.5,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.32,100,,,Fee Schedule,100% of Fee Schedule,95.89,100,,,Fee Schedule,100% of Fee Schedule,95.89,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,64.98,100,,,Fee Schedule,100% of UHC Fee Schedule,64.98,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,242.55,
SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2,1000043,CDM,983,RC,11303,HCPCS,Outpatient,,,489,293.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,268.95,55,,,percent of total billed charges,55% of total billed charges,268.95,55,,,percent of total billed charges,55% of total billed charges,113.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,119.68,180,,,Fee Schedule,180% of CMS Fee Schedule,105.28,350,,,Fee Schedule,350% of CMS OPPS Rate,75.2,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.29,100,,,Fee Schedule,100% of Fee Schedule,113.55,100,,,Fee Schedule,100% of Fee Schedule,113.55,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,76.45,100,,,Fee Schedule,100% of UHC Fee Schedule,76.45,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.2,268.95,
SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5,1000044,CDM,983,RC,11305,HCPCS,Outpatient,,,308,184.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,169.4,55,,,percent of total billed charges,55% of total billed charges,169.4,55,,,percent of total billed charges,55% of total billed charges,60.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,66.35,180,,,Fee Schedule,180% of CMS Fee Schedule,55.79,350,,,Fee Schedule,350% of CMS OPPS Rate,39.85,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.35,100,,,Fee Schedule,100% of Fee Schedule,60.17,100,,,Fee Schedule,100% of Fee Schedule,60.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of UHC Fee Schedule,42.64,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.85,169.4,
SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6,1000045,CDM,983,RC,11306,HCPCS,Outpatient,,,381,228.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.77,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.55,55,,,percent of total billed charges,55% of total billed charges,209.55,55,,,percent of total billed charges,55% of total billed charges,79.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,96.84,180,,,Fee Schedule,180% of CMS Fee Schedule,73.89,350,,,Fee Schedule,350% of CMS OPPS Rate,52.78,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.65,100,,,Fee Schedule,100% of Fee Schedule,79.7,100,,,Fee Schedule,100% of Fee Schedule,79.7,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.99,100,,,Fee Schedule,100% of UHC Fee Schedule,61.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.78,209.55,
SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0,1000047,CDM,983,RC,11310,HCPCS,Outpatient,,,355,213,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,195.25,55,,,percent of total billed charges,55% of total billed charges,195.25,55,,,percent of total billed charges,55% of total billed charges,72.43,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.17,180,,,Fee Schedule,180% of CMS Fee Schedule,67.16,350,,,Fee Schedule,350% of CMS OPPS Rate,47.97,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.43,100,,,Fee Schedule,100% of Fee Schedule,72.43,100,,,Fee Schedule,100% of Fee Schedule,72.43,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,45.47,100,,,Fee Schedule,100% of UHC Fee Schedule,45.47,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.47,195.25,
SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-,1000048,CDM,983,RC,11311,HCPCS,Outpatient,,,388.68,233.21,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,213.77,55,,,percent of total billed charges,55% of total billed charges,213.77,55,,,percent of total billed charges,55% of total billed charges,100.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,103.54,180,,,Fee Schedule,180% of CMS Fee Schedule,92.76,350,,,Fee Schedule,350% of CMS OPPS Rate,66.26,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.92,100,,,Fee Schedule,100% of Fee Schedule,100.05,100,,,Fee Schedule,100% of Fee Schedule,100.05,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,66.13,100,,,Fee Schedule,100% of UHC Fee Schedule,66.13,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.13,213.77,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,1000051,CDM,983,RC,11401,HCPCS,Outpatient,,,782.95,469.77,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,430.62,55,,,percent of total billed charges,55% of total billed charges,430.62,55,,,percent of total billed charges,55% of total billed charges,155.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,150.05,180,,,Fee Schedule,180% of CMS Fee Schedule,144.1,350,,,Fee Schedule,350% of CMS OPPS Rate,102.93,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.55,100,,,Fee Schedule,100% of Fee Schedule,155.42,100,,,Fee Schedule,100% of Fee Schedule,155.42,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,184.23,100,,,Fee Schedule,100% of UHC Fee Schedule,184.23,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.93,430.62,
EXC B9 LESION MRGN XCP SK TG T/A/L 1.1-2,1000052,CDM,983,RC,11402,HCPCS,Outpatient,,,526,315.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,289.3,55,,,percent of total billed charges,55% of total billed charges,289.3,55,,,percent of total billed charges,55% of total billed charges,171.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.78,180,,,Fee Schedule,180% of CMS Fee Schedule,159.12,350,,,Fee Schedule,350% of CMS OPPS Rate,113.66,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.79,100,,,Fee Schedule,100% of Fee Schedule,171.63,100,,,Fee Schedule,100% of Fee Schedule,171.63,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,209.19,100,,,Fee Schedule,100% of UHC Fee Schedule,209.19,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.66,289.3,
EXC B9 LESION MRGN XCP SK TG T/A/L 2.1-3,1000053,CDM,983,RC,11403,HCPCS,Outpatient,,,612,367.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,336.6,55,,,percent of total billed charges,55% of total billed charges,336.6,55,,,percent of total billed charges,55% of total billed charges,221.89,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,210.64,180,,,Fee Schedule,180% of CMS Fee Schedule,205.72,350,,,Fee Schedule,350% of CMS OPPS Rate,146.94,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.93,100,,,Fee Schedule,100% of Fee Schedule,221.89,100,,,Fee Schedule,100% of Fee Schedule,221.89,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,135.84,100,,,Fee Schedule,100% of UHC Fee Schedule,135.84,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.84,336.6,
EX BLSN INC MRGN EX S/N/H/F/G;DM<=.6-1CM,1000057,CDM,983,RC,11421,HCPCS,Outpatient,,,496,297.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,272.8,55,,,percent of total billed charges,55% of total billed charges,272.8,55,,,percent of total billed charges,55% of total billed charges,164.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,170.37,180,,,Fee Schedule,180% of CMS Fee Schedule,152.5,350,,,Fee Schedule,350% of CMS OPPS Rate,108.93,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.77,100,,,Fee Schedule,100% of Fee Schedule,164.48,100,,,Fee Schedule,100% of Fee Schedule,164.48,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,109.9,100,,,Fee Schedule,100% of UHC Fee Schedule,109.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.93,272.8,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,1000058,CDM,983,RC,11422,HCPCS,Outpatient,,,559,335.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.82,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,307.45,55,,,percent of total billed charges,55% of total billed charges,307.45,55,,,percent of total billed charges,55% of total billed charges,202.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,199.58,180,,,Fee Schedule,180% of CMS Fee Schedule,188.05,350,,,Fee Schedule,350% of CMS OPPS Rate,134.32,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.9,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,128.87,100,,,Fee Schedule,100% of UHC Fee Schedule,128.87,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.87,307.45,
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 3,1000060,CDM,960,RC,11424,HCPCS,Outpatient,,,746,447.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,410.3,55,,,percent of total billed charges,55% of total billed charges,410.3,55,,,percent of total billed charges,55% of total billed charges,271.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,276.25,180,,,Fee Schedule,180% of CMS Fee Schedule,251.52,350,,,Fee Schedule,350% of CMS OPPS Rate,179.66,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.29,100,,,Fee Schedule,100% of Fee Schedule,271.29,100,,,Fee Schedule,100% of Fee Schedule,271.29,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,178.14,100,,,Fee Schedule,100% of UHC Fee Schedule,178.14,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.14,410.3,
Separation and removal of the entire nail plate or a portion of nail plate,1000089,CDM,983,RC,11730,HCPCS,Outpatient,,,332,199.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,182.6,55,,,percent of total billed charges,55% of total billed charges,182.6,55,,,percent of total billed charges,55% of total billed charges,84.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,112.03,180,,,Fee Schedule,180% of CMS Fee Schedule,77.95,350,,,Fee Schedule,350% of CMS OPPS Rate,55.68,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.47,100,,,Fee Schedule,100% of Fee Schedule,84.08,100,,,Fee Schedule,100% of Fee Schedule,84.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of UHC Fee Schedule,72.14,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.68,182.6,
Injections to remove up to 7 lesions on the skin,1000098,CDM,960,RC,11900,HCPCS,Outpatient,,,177,106.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.35,55,,,percent of total billed charges,55% of total billed charges,97.35,55,,,percent of total billed charges,55% of total billed charges,47.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,49.03,180,,,Fee Schedule,180% of CMS Fee Schedule,44.34,350,,,Fee Schedule,350% of CMS OPPS Rate,31.67,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.52,100,,,Fee Schedule,100% of Fee Schedule,47.82,100,,,Fee Schedule,100% of Fee Schedule,47.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,31.24,100,,,Fee Schedule,100% of UHC Fee Schedule,31.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.24,97.35,
INSJ NON-BIODEGRADABLE DRUG DELIVERY IMP,1000101,CDM,960,RC,11981,HCPCS,Outpatient,,,453,271.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.07,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,249.15,55,,,percent of total billed charges,55% of total billed charges,249.15,55,,,percent of total billed charges,55% of total billed charges,129.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,148.9,180,,,Fee Schedule,180% of CMS Fee Schedule,119.94,350,,,Fee Schedule,350% of CMS OPPS Rate,85.67,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.8,100,,,Fee Schedule,100% of Fee Schedule,129.36,100,,,Fee Schedule,100% of Fee Schedule,129.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,95.5,100,,,Fee Schedule,100% of UHC Fee Schedule,95.5,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.67,279,
REMOVAL NON-BIODEGRADABLE DRUG DELIVERY,1000102,CDM,960,RC,11982,HCPCS,Outpatient,,,509,305.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,279.95,55,,,percent of total billed charges,55% of total billed charges,279.95,55,,,percent of total billed charges,55% of total billed charges,154.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,181.64,180,,,Fee Schedule,180% of CMS Fee Schedule,143.32,350,,,Fee Schedule,350% of CMS OPPS Rate,102.37,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.58,100,,,Fee Schedule,100% of Fee Schedule,154.58,100,,,Fee Schedule,100% of Fee Schedule,154.58,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,116.72,100,,,Fee Schedule,100% of UHC Fee Schedule,116.72,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.37,313,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",1000104,CDM,983,RC,12001,HCPCS,Outpatient,,,286,171.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.94,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,157.3,55,,,percent of total billed charges,55% of total billed charges,157.3,55,,,percent of total billed charges,55% of total billed charges,68.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,171.27,180,,,Fee Schedule,180% of CMS Fee Schedule,63.36,350,,,Fee Schedule,350% of CMS OPPS Rate,45.26,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.04,100,,,Fee Schedule,100% of Fee Schedule,68.34,100,,,Fee Schedule,100% of Fee Schedule,68.34,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,148.41,100,,,Fee Schedule,100% of UHC Fee Schedule,148.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.26,171.27,
SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6,1000106,CDM,983,RC,12004,HCPCS,Outpatient,,,411,246.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.69,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,226.05,55,,,percent of total billed charges,55% of total billed charges,226.05,55,,,percent of total billed charges,55% of total billed charges,112.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,226.31,180,,,Fee Schedule,180% of CMS Fee Schedule,104.73,350,,,Fee Schedule,350% of CMS OPPS Rate,74.81,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.36,100,,,Fee Schedule,100% of Fee Schedule,112.96,100,,,Fee Schedule,100% of Fee Schedule,112.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,145.35,100,,,Fee Schedule,100% of UHC Fee Schedule,145.35,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.81,243,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",1000109,CDM,983,RC,12011,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,55,,,percent of total billed charges,55% of total billed charges,192.5,55,,,percent of total billed charges,55% of total billed charges,84.74,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.67,180,,,Fee Schedule,180% of CMS Fee Schedule,78.57,350,,,Fee Schedule,350% of CMS OPPS Rate,56.12,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.81,100,,,Fee Schedule,100% of Fee Schedule,84.74,100,,,Fee Schedule,100% of Fee Schedule,84.74,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,161.12,100,,,Fee Schedule,100% of UHC Fee Schedule,161.12,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.12,192.5,
REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,1000114,CDM,983,RC,12034,HCPCS,Outpatient,,,991,594.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,545.05,55,,,percent of total billed charges,55% of total billed charges,545.05,55,,,percent of total billed charges,55% of total billed charges,313.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,301,180,,,Fee Schedule,180% of CMS Fee Schedule,290.91,350,,,Fee Schedule,350% of CMS OPPS Rate,207.79,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.77,100,,,Fee Schedule,100% of Fee Schedule,313.76,100,,,Fee Schedule,100% of Fee Schedule,313.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,193.28,100,,,Fee Schedule,100% of UHC Fee Schedule,193.28,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.28,545.05,
REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5,1000118,CDM,983,RC,12041,HCPCS,Outpatient,,,748,448.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,411.4,55,,,percent of total billed charges,55% of total billed charges,411.4,55,,,percent of total billed charges,55% of total billed charges,225.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,240.66,180,,,Fee Schedule,180% of CMS Fee Schedule,208.68,350,,,Fee Schedule,350% of CMS OPPS Rate,149.06,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.44,100,,,Fee Schedule,100% of Fee Schedule,225.08,100,,,Fee Schedule,100% of Fee Schedule,225.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,154.38,100,,,Fee Schedule,100% of UHC Fee Schedule,154.38,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.06,411.4,
REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 C,1000122,CDM,983,RC,12051,HCPCS,Outpatient,,,814,488.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.85,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,447.7,55,,,percent of total billed charges,55% of total billed charges,447.7,55,,,percent of total billed charges,55% of total billed charges,257.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,266.69,180,,,Fee Schedule,180% of CMS Fee Schedule,238.98,350,,,Fee Schedule,350% of CMS OPPS Rate,170.7,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.84,100,,,Fee Schedule,100% of Fee Schedule,257.76,100,,,Fee Schedule,100% of Fee Schedule,257.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,100% of UHC Fee Schedule,171.4,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.7,447.7,
Destruction of pre-cancerous lesion,1000190,CDM,960,RC,17000,HCPCS,Outpatient,,,208,124.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,114.4,55,,,percent of total billed charges,55% of total billed charges,114.4,55,,,percent of total billed charges,55% of total billed charges,78.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,74.29,180,,,Fee Schedule,180% of CMS Fee Schedule,73.21,350,,,Fee Schedule,350% of CMS OPPS Rate,52.29,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.16,100,,,Fee Schedule,100% of Fee Schedule,78.96,100,,,Fee Schedule,100% of Fee Schedule,78.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,92.24,100,,,Fee Schedule,100% of UHC Fee Schedule,92.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.29,114.4,
Destruction of 2-14 pre-cancerous lesions,1000191,CDM,960,RC,17003,HCPCS,Outpatient,,,17,10.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,9.35,55,,,percent of total billed charges,55% of total billed charges,9.35,55,,,percent of total billed charges,55% of total billed charges,3.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,14.99,180,,,Fee Schedule,180% of CMS Fee Schedule,3.5,350,,,Fee Schedule,350% of CMS OPPS Rate,2.5,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.6,100,,,Fee Schedule,100% of Fee Schedule,3.79,100,,,Fee Schedule,100% of Fee Schedule,3.79,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,11.73,100,,,Fee Schedule,100% of UHC Fee Schedule,11.73,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.5,28,
Draining or injecting medication into a small joint/bursa without ultrasound,1000228,CDM,960,RC,20600,HCPCS,Outpatient,,,155,93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.71,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,103.67,100,,,Fee Schedule,pays at 100% of fee Schedule,103.67,100,,,Fee Schedule,pays at 100% of fee Schedule,55.13,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,71.01,180,,,Fee Schedule,180% of CMS Fee Schedule,51.11,350,,,Fee Schedule,350% of CMS OPPS Rate,36.51,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,100,,,Fee Schedule,100% of Fee Schedule,55.13,100,,,Fee Schedule,100% of Fee Schedule,55.13,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,90.24,100,,,Fee Schedule,100% of UHC Fee Schedule,90.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.51,103.67,
Draining or injecting medication into a major joint/bursa without ultrasound,1000232,CDM,983,RC,20610,HCPCS,Outpatient,,,195,117,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,137.62,100,,,Fee Schedule,pays at 100% of fee Schedule,137.62,100,,,Fee Schedule,pays at 100% of fee Schedule,70.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,86.09,180,,,Fee Schedule,180% of CMS Fee Schedule,65.46,350,,,Fee Schedule,350% of CMS OPPS Rate,46.76,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.86,100,,,Fee Schedule,100% of Fee Schedule,70.61,100,,,Fee Schedule,100% of Fee Schedule,70.61,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,111.68,100,,,Fee Schedule,100% of UHC Fee Schedule,111.68,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.76,137.62,
MNL PREP&INSJ I-ARTIC RX DEV,1000246,CDM,960,RC,20704,HCPCS,Outpatient,,,456,273.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.88,50,,,percent of total billed charges,pays at 50% of total billed charges,250.8,55,,,percent of total billed charges,55% of total billed charges,250.8,55,,,percent of total billed charges,55% of total billed charges,273.6,60,,,percent of total billed charges,pays at 60% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.6,60,,,percent of total billed charges,60% of total billed charges,273.6,60,,,percent of total billed charges,60% of total billed charges,273.6,60,,,percent of total billed charges,60% of total billed charges for outpatient setting,,,,,Other,Not Separately reimbursable,150.23,100,,,Fee Schedule,100% of UHC Fee Schedule,150.23,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.88,273.6,
CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,1000880,CDM,960,RC,30901,HCPCS,Outpatient,,,426,255.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,234.3,55,,,percent of total billed charges,55% of total billed charges,234.3,55,,,percent of total billed charges,55% of total billed charges,87.5,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,108.95,180,,,Fee Schedule,180% of CMS Fee Schedule,81.13,350,,,Fee Schedule,350% of CMS OPPS Rate,57.95,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.86,100,,,Fee Schedule,100% of Fee Schedule,87.5,100,,,Fee Schedule,100% of Fee Schedule,87.5,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,103.89,100,,,Fee Schedule,100% of UHC Fee Schedule,103.89,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.95,234.3,
INTUBATION ENDOTRACHEAL EMERGENCY PROCED,1000901,CDM,983,RC,31500,HCPCS,Outpatient,,,478,286.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.53,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,262.9,55,,,percent of total billed charges,55% of total billed charges,262.9,55,,,percent of total billed charges,55% of total billed charges,221.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,202.99,180,,,Fee Schedule,180% of CMS Fee Schedule,204.92,350,,,Fee Schedule,350% of CMS OPPS Rate,146.37,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.53,100,,,Fee Schedule,100% of Fee Schedule,221.02,100,,,Fee Schedule,100% of Fee Schedule,221.02,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,317.3,100,,,Fee Schedule,100% of UHC Fee Schedule,317.3,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.37,317.3,
INSERTION INTRA-AORTIC BALLOON ASSIST DE,1001036,CDM,983,RC,33967,HCPCS,Outpatient,,,895,537,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.62,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,492.25,55,,,percent of total billed charges,55% of total billed charges,492.25,55,,,percent of total billed charges,55% of total billed charges,413.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,462.31,180,,,Fee Schedule,180% of CMS Fee Schedule,383.25,350,,,Fee Schedule,350% of CMS OPPS Rate,273.75,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.09,100,,,Fee Schedule,100% of Fee Schedule,413.36,100,,,Fee Schedule,100% of Fee Schedule,413.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,405.18,100,,,Fee Schedule,100% of UHC Fee Schedule,405.18,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.75,539,
INSJ NONTUNNLD CENTRL VENS CATH AG;>=5,1001118,CDM,960,RC,36556,HCPCS,Outpatient,,,428.4,257.04,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,235.62,55,,,percent of total billed charges,55% of total billed charges,235.62,55,,,percent of total billed charges,55% of total billed charges,132.41,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,227,180,,,Fee Schedule,180% of CMS Fee Schedule,122.77,350,,,Fee Schedule,350% of CMS OPPS Rate,87.69,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.43,100,,,Fee Schedule,100% of Fee Schedule,132.41,100,,,Fee Schedule,100% of Fee Schedule,132.41,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,273.24,100,,,Fee Schedule,100% of UHC Fee Schedule,273.24,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.69,273.24,
ABDOM PARACENTESIS DX/THER W/IMAGING GUI,1001424,CDM,983,RC,49083,HCPCS,Outpatient,,,328.77,197.26,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.15,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,180.82,55,,,percent of total billed charges,55% of total billed charges,180.82,55,,,percent of total billed charges,55% of total billed charges,165.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,153.43,350,,,Fee Schedule,350% of CMS OPPS Rate,109.59,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.26,60,,,percent of total billed charges,60% of total billed charges,165.48,100,,,Fee Schedule,100% of Fee Schedule,165.48,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,374.48,100,,,Fee Schedule,100% of UHC Fee Schedule,374.48,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.59,374.48,
LAPS ABD PRTM&OMENTUM DX W/WO SPEC BR/WA,1001428,CDM,960,RC,49320,HCPCS,Outpatient,,,1094,656.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,601.7,55,,,percent of total billed charges,55% of total billed charges,601.7,55,,,percent of total billed charges,55% of total billed charges,504.79,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,546.66,180,,,Fee Schedule,180% of CMS Fee Schedule,468.02,350,,,Fee Schedule,350% of CMS OPPS Rate,334.3,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.69,100,,,Fee Schedule,100% of Fee Schedule,504.79,100,,,Fee Schedule,100% of Fee Schedule,504.79,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,467.54,100,,,Fee Schedule,100% of UHC Fee Schedule,467.54,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.3,680,
URTROLITHOTOMY UPPER ONE-THIRD URETER,1001470,CDM,983,RC,50610,HCPCS,Outpatient,,,3167,1900.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1670.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,1741.85,55,,,percent of total billed charges,55% of total billed charges,1741.85,55,,,percent of total billed charges,55% of total billed charges,1453.3,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,1591.11,180,,,Fee Schedule,180% of CMS Fee Schedule,1352.26,350,,,Fee Schedule,350% of CMS OPPS Rate,965.9,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1749.97,100,,,Fee Schedule,100% of Fee Schedule,1453.3,100,,,Fee Schedule,100% of Fee Schedule,1453.3,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,980.43,100,,,Fee Schedule,100% of UHC Fee Schedule,980.43,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1968,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,965.9,1968,
I&D VULVA/PERINEAL ABSCESS,1001582,CDM,983,RC,56405,HCPCS,Outpatient,,,351,210.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.05,55,,,percent of total billed charges,55% of total billed charges,193.05,55,,,percent of total billed charges,55% of total billed charges,167.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,176.36,180,,,Fee Schedule,180% of CMS Fee Schedule,155.6,350,,,Fee Schedule,350% of CMS OPPS Rate,111.14,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.49,100,,,Fee Schedule,100% of Fee Schedule,167.82,100,,,Fee Schedule,100% of Fee Schedule,167.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,110.27,100,,,Fee Schedule,100% of UHC Fee Schedule,110.27,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.27,193.05,
BIOPSY VULVA/PERINEUM 1 LESION SPX,1001588,CDM,960,RC,56605,HCPCS,Outpatient,,,264,158.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.79,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.2,55,,,percent of total billed charges,55% of total billed charges,145.2,55,,,percent of total billed charges,55% of total billed charges,91.69,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,110.99,180,,,Fee Schedule,180% of CMS Fee Schedule,85.01,350,,,Fee Schedule,350% of CMS OPPS Rate,60.72,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.99,100,,,Fee Schedule,100% of Fee Schedule,91.69,100,,,Fee Schedule,100% of Fee Schedule,91.69,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.72,145.2,
DESTRUCTION VAGINAL LESIONS SIMPLE,1001595,CDM,983,RC,57061,HCPCS,Outpatient,,,363,217.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.13,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,199.65,55,,,percent of total billed charges,55% of total billed charges,199.65,55,,,percent of total billed charges,55% of total billed charges,151.83,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,160.79,180,,,Fee Schedule,180% of CMS Fee Schedule,140.77,350,,,Fee Schedule,350% of CMS OPPS Rate,100.55,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.29,100,,,Fee Schedule,100% of Fee Schedule,151.83,100,,,Fee Schedule,100% of Fee Schedule,151.83,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,100.66,100,,,Fee Schedule,100% of UHC Fee Schedule,100.66,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.55,199.65,
BIOPSY VAGINAL MUCOSA SIMPLE,1001596,CDM,960,RC,57100,HCPCS,Outpatient,,,289,173.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,158.95,55,,,percent of total billed charges,55% of total billed charges,158.95,55,,,percent of total billed charges,55% of total billed charges,102.8,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,119.68,180,,,Fee Schedule,180% of CMS Fee Schedule,95.31,350,,,Fee Schedule,350% of CMS OPPS Rate,68.08,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.42,100,,,Fee Schedule,100% of Fee Schedule,102.8,100,,,Fee Schedule,100% of Fee Schedule,102.8,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,74.46,100,,,Fee Schedule,100% of UHC Fee Schedule,74.46,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.08,158.95,
EXCISION VAGINAL CYST/TUMOR,1001598,CDM,960,RC,57135,HCPCS,Outpatient,,,620,372,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.65,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,341,55,,,percent of total billed charges,55% of total billed charges,341,55,,,percent of total billed charges,55% of total billed charges,266.48,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,299.83,180,,,Fee Schedule,180% of CMS Fee Schedule,247.07,350,,,Fee Schedule,350% of CMS OPPS Rate,176.48,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.41,100,,,Fee Schedule,100% of Fee Schedule,266.48,100,,,Fee Schedule,100% of Fee Schedule,266.48,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,187.08,100,,,Fee Schedule,100% of UHC Fee Schedule,187.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.48,350,
COLPOSCOPY CERVIX UPPER/ADJACENT VAGINA,1001614,CDM,960,RC,57452,HCPCS,Outpatient,,,351,210.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,193.05,55,,,percent of total billed charges,55% of total billed charges,193.05,55,,,percent of total billed charges,55% of total billed charges,139.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,159.21,180,,,Fee Schedule,180% of CMS Fee Schedule,129.11,350,,,Fee Schedule,350% of CMS OPPS Rate,92.22,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.33,100,,,Fee Schedule,100% of Fee Schedule,139.25,100,,,Fee Schedule,100% of Fee Schedule,139.25,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,99.25,100,,,Fee Schedule,100% of UHC Fee Schedule,99.25,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.22,193.05,
Biopsy of cervix or uterus,1001615,CDM,960,RC,57454,HCPCS,Outpatient,,,492,295.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,270.6,55,,,percent of total billed charges,55% of total billed charges,270.6,55,,,percent of total billed charges,55% of total billed charges,202.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,245.59,180,,,Fee Schedule,180% of CMS Fee Schedule,188.05,350,,,Fee Schedule,350% of CMS OPPS Rate,134.32,102,,,Fee Schedule,102% of CMS OPPS Rate,194,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.47,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,202.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,153.06,100,,,Fee Schedule,100% of UHC Fee Schedule,153.06,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.32,270.6,
COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/C,1001616,CDM,960,RC,57455,HCPCS,Outpatient,,,459,275.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.9,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,252.45,55,,,percent of total billed charges,55% of total billed charges,252.45,55,,,percent of total billed charges,55% of total billed charges,167.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,203.33,180,,,Fee Schedule,180% of CMS Fee Schedule,154.91,350,,,Fee Schedule,350% of CMS OPPS Rate,110.65,102,,,Fee Schedule,102% of CMS OPPS Rate,299,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.42,100,,,Fee Schedule,100% of Fee Schedule,167.08,100,,,Fee Schedule,100% of Fee Schedule,167.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,126.63,100,,,Fee Schedule,100% of UHC Fee Schedule,126.63,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.65,299,
COLPOSCOPY CERVIX ENDOCERVICAL CURETTAGE,1001617,CDM,983,RC,57456,HCPCS,Outpatient,,,432,259.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.42,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,237.6,55,,,percent of total billed charges,55% of total billed charges,237.6,55,,,percent of total billed charges,55% of total billed charges,155.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,189.45,180,,,Fee Schedule,180% of CMS Fee Schedule,143.95,350,,,Fee Schedule,350% of CMS OPPS Rate,102.82,102,,,Fee Schedule,102% of CMS OPPS Rate,217,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.54,100,,,Fee Schedule,100% of Fee Schedule,155.26,100,,,Fee Schedule,100% of Fee Schedule,155.26,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,117.97,100,,,Fee Schedule,100% of UHC Fee Schedule,117.97,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.82,237.6,
Biopsy of the lining of the uterus,1001627,CDM,983,RC,58100,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,192.5,55,,,percent of total billed charges,55% of total billed charges,192.5,55,,,percent of total billed charges,55% of total billed charges,107.01,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,158.96,180,,,Fee Schedule,180% of CMS Fee Schedule,99.22,350,,,Fee Schedule,350% of CMS OPPS Rate,70.87,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.7,100,,,Fee Schedule,100% of Fee Schedule,107.01,100,,,Fee Schedule,100% of Fee Schedule,107.01,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,99.01,100,,,Fee Schedule,100% of UHC Fee Schedule,99.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.87,192.5,
INSERTION INTRAUTERINE DEVICE IUD,1001637,CDM,960,RC,58300,HCPCS,Outpatient,,,555,333,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,305.25,55,,,percent of total billed charges,55% of total billed charges,305.25,55,,,percent of total billed charges,55% of total billed charges,82.93,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,99.5,180,,,Fee Schedule,180% of CMS Fee Schedule,76.89,350,,,Fee Schedule,350% of CMS OPPS Rate,54.92,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333,60,,,percent of total billed charges,60% of total billed charges,82.93,100,,,Fee Schedule,100% of Fee Schedule,82.93,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.9,100,,,Fee Schedule,100% of UHC Fee Schedule,61.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.92,333,
REMOVAL INTRAUTERINE DEVICE IUD,1001638,CDM,960,RC,58301,HCPCS,Outpatient,,,305,183,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,167.75,55,,,percent of total billed charges,55% of total billed charges,167.75,55,,,percent of total billed charges,55% of total billed charges,102.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,125.19,180,,,Fee Schedule,180% of CMS Fee Schedule,95.07,350,,,Fee Schedule,350% of CMS OPPS Rate,67.91,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.11,100,,,Fee Schedule,100% of Fee Schedule,102.54,100,,,Fee Schedule,100% of Fee Schedule,102.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,77.87,100,,,Fee Schedule,100% of UHC Fee Schedule,77.87,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,167.75,
UTERINE SUSPENSION W/WO SHORTENING LIGAM,1001640,CDM,983,RC,58400,HCPCS,Outpatient,,,1434,860.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.57,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,788.7,55,,,percent of total billed charges,55% of total billed charges,788.7,55,,,percent of total billed charges,55% of total billed charges,671.03,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,714.94,180,,,Fee Schedule,180% of CMS Fee Schedule,622.15,350,,,Fee Schedule,350% of CMS OPPS Rate,444.39,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.27,100,,,Fee Schedule,100% of Fee Schedule,671.03,100,,,Fee Schedule,100% of Fee Schedule,671.03,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,446.18,100,,,Fee Schedule,100% of UHC Fee Schedule,446.18,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.39,882,
RMVL FB XTRNL AUDITORY CANAL W/O ANES,1001836,CDM,960,RC,69200,HCPCS,Outpatient,,,258,154.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,141.9,55,,,percent of total billed charges,55% of total billed charges,141.9,55,,,percent of total billed charges,55% of total billed charges,71.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,88.63,180,,,Fee Schedule,180% of CMS Fee Schedule,66.39,350,,,Fee Schedule,350% of CMS OPPS Rate,47.42,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.24,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,54.19,100,,,Fee Schedule,100% of UHC Fee Schedule,54.19,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.42,183.24,
Removal of ear wax from one or both ears,1001839,CDM,960,RC,69210,HCPCS,Outpatient,,,155,93,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,85.25,55,,,percent of total billed charges,55% of total billed charges,85.25,55,,,percent of total billed charges,55% of total billed charges,50.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,58.5,180,,,Fee Schedule,180% of CMS Fee Schedule,46.65,350,,,Fee Schedule,350% of CMS OPPS Rate,33.32,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.24,100,,,Fee Schedule,100% of Fee Schedule,50.31,100,,,Fee Schedule,100% of Fee Schedule,50.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,63.92,100,,,Fee Schedule,100% of UHC Fee Schedule,63.92,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.32,85.25,
Eye exam on an established patient,1002471,CDM,962,RC,92012,HCPCS,Outpatient,,,273,163.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,150.15,55,,,percent of total billed charges,55% of total billed charges,150.15,55,,,percent of total billed charges,55% of total billed charges,51.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.9,180,,,Fee Schedule,180% of CMS Fee Schedule,72.56,350,,,Fee Schedule,350% of CMS OPPS Rate,51.83,102,,,Fee Schedule,102% of CMS OPPS Rate,91,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.93,100,,,Fee Schedule,100% of Fee Schedule,51.31,100,,,Fee Schedule,100% of Fee Schedule,51.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,30.17,100,,,Fee Schedule,100% of UHC Fee Schedule,30.17,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.17,150.15,
Eye exam and treatment for established patient,1002472,CDM,962,RC,92014,HCPCS,Outpatient,,,395,237,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,217.25,55,,,percent of total billed charges,55% of total billed charges,217.25,55,,,percent of total billed charges,55% of total billed charges,77.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.35,180,,,Fee Schedule,180% of CMS Fee Schedule,109.73,350,,,Fee Schedule,350% of CMS OPPS Rate,78.38,102,,,Fee Schedule,102% of CMS OPPS Rate,115,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.82,100,,,Fee Schedule,100% of Fee Schedule,77.6,100,,,Fee Schedule,100% of Fee Schedule,77.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,115.87,100,,,Fee Schedule,100% of UHC Fee Schedule,115.87,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.6,217.25,
CARDIOPULMONARY RESUSCITATION,1002490,CDM,983,RC,92950,HCPCS,Outpatient,,,970,582,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.08,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,533.5,55,,,percent of total billed charges,55% of total billed charges,533.5,55,,,percent of total billed charges,55% of total billed charges,189.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,334.78,180,,,Fee Schedule,180% of CMS Fee Schedule,267.9,350,,,Fee Schedule,350% of CMS OPPS Rate,191.36,102,,,Fee Schedule,102% of CMS OPPS Rate,442,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.3,100,,,Fee Schedule,100% of Fee Schedule,189.45,100,,,Fee Schedule,100% of Fee Schedule,189.45,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,338.39,100,,,Fee Schedule,100% of UHC Fee Schedule,338.39,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.45,533.5,
Routine EKG using at least 12 leads including interpretation and report,1002498,CDM,983,RC,93000,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.16,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,16.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,43.22,180,,,Fee Schedule,180% of CMS Fee Schedule,22.76,350,,,Fee Schedule,350% of CMS OPPS Rate,16.26,102,,,Fee Schedule,102% of CMS OPPS Rate,56,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.3,100,,,Fee Schedule,100% of Fee Schedule,16.1,100,,,Fee Schedule,100% of Fee Schedule,16.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,41.35,100,,,Fee Schedule,100% of UHC Fee Schedule,41.35,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.1,56,
ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY,1002499,CDM,983,RC,93005,HCPCS,Outpatient,,,26,15.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.95,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,14.3,55,,,percent of total billed charges,55% of total billed charges,14.3,55,,,percent of total billed charges,55% of total billed charges,7.7,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.43,180,,,Fee Schedule,180% of CMS Fee Schedule,10.89,350,,,Fee Schedule,350% of CMS OPPS Rate,7.78,102,,,Fee Schedule,102% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.4,100,,,Fee Schedule,100% of Fee Schedule,7.7,100,,,Fee Schedule,100% of Fee Schedule,7.7,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,24.35,100,,,Fee Schedule,100% of UHC Fee Schedule,24.35,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.7,33,
ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY,1002500,CDM,983,RC,93010,HCPCS,Outpatient,,,28,16.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,15.4,55,,,percent of total billed charges,55% of total billed charges,15.4,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,24,
Test to determine heart abnormalities,1002501,CDM,983,RC,93015,HCPCS,Outpatient,,,223,133.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.05,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,122.65,55,,,percent of total billed charges,55% of total billed charges,122.65,55,,,percent of total billed charges,55% of total billed charges,67.08,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,174.51,180,,,Fee Schedule,180% of CMS Fee Schedule,94.86,350,,,Fee Schedule,350% of CMS OPPS Rate,67.76,102,,,Fee Schedule,102% of CMS OPPS Rate,223,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.23,100,,,Fee Schedule,100% of Fee Schedule,67.08,100,,,Fee Schedule,100% of Fee Schedule,67.08,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,168.7,100,,,Fee Schedule,100% of UHC Fee Schedule,168.7,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.08,233,
CV STRS TST XERS&/OR RX CONT ECG W/O I&R,1002502,CDM,983,RC,93016,HCPCS,Outpatient,,,73,43.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,40.15,55,,,percent of total billed charges,55% of total billed charges,40.15,55,,,percent of total billed charges,55% of total billed charges,21.98,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.96,180,,,Fee Schedule,180% of CMS Fee Schedule,31.08,350,,,Fee Schedule,350% of CMS OPPS Rate,22.2,102,,,Fee Schedule,102% of CMS OPPS Rate,61,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.86,100,,,Fee Schedule,100% of Fee Schedule,21.98,100,,,Fee Schedule,100% of Fee Schedule,21.98,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,44.85,100,,,Fee Schedule,100% of UHC Fee Schedule,44.85,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.98,61,
CV STRS TST XERS&/OR RX CONT ECG TRCG ON,1002503,CDM,983,RC,93017,HCPCS,Outpatient,,,102,61.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.81,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,56.1,55,,,percent of total billed charges,55% of total billed charges,56.1,55,,,percent of total billed charges,55% of total billed charges,30.49,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,104.99,180,,,Fee Schedule,180% of CMS Fee Schedule,43.12,350,,,Fee Schedule,350% of CMS OPPS Rate,30.8,102,,,Fee Schedule,102% of CMS OPPS Rate,102,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102,100,,,Fee Schedule,100% of Fee Schedule,30.49,100,,,Fee Schedule,100% of Fee Schedule,30.49,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,94.28,100,,,Fee Schedule,100% of UHC Fee Schedule,94.28,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.49,122,
CV STRS TST XERS&/OR RX CONT ECG I&R ONL,1002504,CDM,983,RC,93018,HCPCS,Outpatient,,,48,28.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.46,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,26.4,55,,,percent of total billed charges,55% of total billed charges,26.4,55,,,percent of total billed charges,55% of total billed charges,14.61,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,27.54,180,,,Fee Schedule,180% of CMS Fee Schedule,20.66,350,,,Fee Schedule,350% of CMS OPPS Rate,14.76,102,,,Fee Schedule,102% of CMS OPPS Rate,48,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,100,,,Fee Schedule,100% of Fee Schedule,14.61,100,,,Fee Schedule,100% of Fee Schedule,14.61,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,29.57,100,,,Fee Schedule,100% of UHC Fee Schedule,29.57,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.61,50,
XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I,1002505,CDM,983,RC,93224,HCPCS,Outpatient,,,278,166.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.9,55,,,percent of total billed charges,55% of total billed charges,152.9,55,,,percent of total billed charges,55% of total billed charges,81.97,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,261.94,180,,,Fee Schedule,180% of CMS Fee Schedule,115.92,350,,,Fee Schedule,350% of CMS OPPS Rate,82.8,102,,,Fee Schedule,102% of CMS OPPS Rate,278,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.1,100,,,Fee Schedule,100% of Fee Schedule,81.97,100,,,Fee Schedule,100% of Fee Schedule,81.97,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,238.8,100,,,Fee Schedule,100% of UHC Fee Schedule,238.8,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.97,345,
XTRNL ECG & 48 HR RECORDING,1002506,CDM,983,RC,93225,HCPCS,Outpatient,,,79,47.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,43.45,55,,,percent of total billed charges,55% of total billed charges,43.45,55,,,percent of total billed charges,55% of total billed charges,23.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,77.42,180,,,Fee Schedule,180% of CMS Fee Schedule,32.83,350,,,Fee Schedule,350% of CMS OPPS Rate,23.45,102,,,Fee Schedule,102% of CMS OPPS Rate,79,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.21,100,,,Fee Schedule,100% of Fee Schedule,23.22,100,,,Fee Schedule,100% of Fee Schedule,23.22,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,70.13,100,,,Fee Schedule,100% of UHC Fee Schedule,70.13,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.22,90,
EXTERNAL ECG SCANNING ANALYSIS REPORT,1002507,CDM,983,RC,93226,HCPCS,Outpatient,,,112,67.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.51,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.6,55,,,percent of total billed charges,55% of total billed charges,61.6,55,,,percent of total billed charges,55% of total billed charges,32.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,136.64,180,,,Fee Schedule,180% of CMS Fee Schedule,46.26,350,,,Fee Schedule,350% of CMS OPPS Rate,33.04,102,,,Fee Schedule,102% of CMS OPPS Rate,112,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.61,100,,,Fee Schedule,100% of Fee Schedule,32.71,100,,,Fee Schedule,100% of Fee Schedule,32.71,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,88.6,100,,,Fee Schedule,100% of UHC Fee Schedule,88.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.71,159,
XTRNL ECG CONTINUOUS RHYTHM W/I&R UP TO,1002508,CDM,983,RC,93227,HCPCS,Outpatient,,,87,52.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.85,55,,,percent of total billed charges,55% of total billed charges,47.85,55,,,percent of total billed charges,55% of total billed charges,26.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.88,180,,,Fee Schedule,180% of CMS Fee Schedule,36.85,350,,,Fee Schedule,350% of CMS OPPS Rate,26.32,102,,,Fee Schedule,102% of CMS OPPS Rate,87,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.25,100,,,Fee Schedule,100% of Fee Schedule,26.06,100,,,Fee Schedule,100% of Fee Schedule,26.06,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,51.98,100,,,Fee Schedule,100% of UHC Fee Schedule,51.98,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.06,97,
XTRNL MOBILE CV TELEMETRY W/I&REPORT 30,1002509,CDM,983,RC,93228,HCPCS,Outpatient,,,86,51.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,47.3,55,,,percent of total billed charges,55% of total billed charges,47.3,55,,,percent of total billed charges,55% of total billed charges,25.85,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,36.55,350,,,Fee Schedule,350% of CMS OPPS Rate,26.11,102,,,Fee Schedule,102% of CMS OPPS Rate,52,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.32,100,,,Fee Schedule,100% of Fee Schedule,25.85,100,,,Fee Schedule,100% of Fee Schedule,25.85,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,26.69,100,,,Fee Schedule,100% of UHC Fee Schedule,26.69,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.85,52,
XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DA,1002510,CDM,983,RC,93272,HCPCS,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.45,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.65,55,,,percent of total billed charges,55% of total billed charges,45.65,55,,,percent of total billed charges,55% of total billed charges,25.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.88,180,,,Fee Schedule,180% of CMS Fee Schedule,35.5,350,,,Fee Schedule,350% of CMS OPPS Rate,25.36,102,,,Fee Schedule,102% of CMS OPPS Rate,68,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.4,100,,,Fee Schedule,100% of Fee Schedule,25.11,100,,,Fee Schedule,100% of Fee Schedule,25.11,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,29.61,100,,,Fee Schedule,100% of UHC Fee Schedule,29.61,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.11,68,
SIGNAL AVERAGED ELECTROCARDIOGRAPHY W/WO,1002511,CDM,983,RC,93278,HCPCS,Outpatient,,,96,57.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,52.8,55,,,percent of total billed charges,55% of total billed charges,52.8,55,,,percent of total billed charges,55% of total billed charges,28.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.92,180,,,Fee Schedule,180% of CMS Fee Schedule,40.67,350,,,Fee Schedule,350% of CMS OPPS Rate,29.05,102,,,Fee Schedule,102% of CMS OPPS Rate,96,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.03,100,,,Fee Schedule,100% of Fee Schedule,28.76,100,,,Fee Schedule,100% of Fee Schedule,28.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,63.03,100,,,Fee Schedule,100% of UHC Fee Schedule,63.03,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.76,161,
PROGRAM EVAL IMPLANTABLE IN PERSN DUAL L,1002513,CDM,960,RC,93280,HCPCS,Outpatient,,,186.24,111.74,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.98,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.43,55,,,percent of total billed charges,55% of total billed charges,102.43,55,,,percent of total billed charges,55% of total billed charges,61.46,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,86.91,350,,,Fee Schedule,350% of CMS OPPS Rate,62.08,102,,,Fee Schedule,102% of CMS OPPS Rate,115,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.65,100,,,Fee Schedule,100% of Fee Schedule,61.46,100,,,Fee Schedule,100% of Fee Schedule,61.46,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,82.4,100,,,Fee Schedule,100% of UHC Fee Schedule,82.4,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.46,119.65,
PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1,1002515,CDM,960,RC,93282,HCPCS,Outpatient,,,194,116.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,106.7,55,,,percent of total billed charges,55% of total billed charges,106.7,55,,,percent of total billed charges,55% of total billed charges,64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,90.51,350,,,Fee Schedule,350% of CMS OPPS Rate,64.65,102,,,Fee Schedule,102% of CMS OPPS Rate,123,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.64,100,,,Fee Schedule,100% of Fee Schedule,64,100,,,Fee Schedule,100% of Fee Schedule,64,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.41,129.64,
INTERROGATION EVAL IN PERSON 1/DUAL/MLT,1002518,CDM,960,RC,93288,HCPCS,Outpatient,,,126.15,75.69,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,69.38,55,,,percent of total billed charges,55% of total billed charges,69.38,55,,,percent of total billed charges,55% of total billed charges,41.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,58.87,350,,,Fee Schedule,350% of CMS OPPS Rate,42.05,102,,,Fee Schedule,102% of CMS OPPS Rate,74,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.84,100,,,Fee Schedule,100% of Fee Schedule,41.63,100,,,Fee Schedule,100% of Fee Schedule,41.63,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,60.93,100,,,Fee Schedule,100% of UHC Fee Schedule,60.93,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.63,77.84,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",1002527,CDM,960,RC,93306,HCPCS,Outpatient,,,644,386.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.5,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,354.2,55,,,percent of total billed charges,55% of total billed charges,354.2,55,,,percent of total billed charges,55% of total billed charges,191.64,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,271.01,350,,,Fee Schedule,350% of CMS OPPS Rate,193.58,102,,,Fee Schedule,102% of CMS OPPS Rate,390,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.7,100,,,Fee Schedule,100% of Fee Schedule,191.64,100,,,Fee Schedule,100% of Fee Schedule,191.64,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,284.72,100,,,Fee Schedule,100% of UHC Fee Schedule,284.72,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,172.76,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.76,469.7,
INTRACUTANEOUS TESTS W/ALLERGENIC EXTRAC,1002581,CDM,960,RC,95024,HCPCS,Outpatient,,,25,15,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.17,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,13.75,55,,,percent of total billed charges,55% of total billed charges,13.75,55,,,percent of total billed charges,55% of total billed charges,1.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,9.38,180,,,Fee Schedule,180% of CMS Fee Schedule,10.51,350,,,Fee Schedule,350% of CMS OPPS Rate,7.51,102,,,Fee Schedule,102% of CMS OPPS Rate,11,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.84,100,,,Fee Schedule,100% of Fee Schedule,1.1,100,,,Fee Schedule,100% of Fee Schedule,1.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,6.96,100,,,Fee Schedule,100% of UHC Fee Schedule,6.96,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.1,13.75,
PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTI,1002583,CDM,960,RC,95165,HCPCS,Outpatient,,,40,24,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,22,55,,,percent of total billed charges,55% of total billed charges,22,55,,,percent of total billed charges,55% of total billed charges,3.2,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,5.96,180,,,Fee Schedule,180% of CMS Fee Schedule,18.4,350,,,Fee Schedule,350% of CMS OPPS Rate,13.14,102,,,Fee Schedule,102% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.28,100,,,Fee Schedule,100% of Fee Schedule,3.2,100,,,Fee Schedule,100% of Fee Schedule,3.2,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,6.46,100,,,Fee Schedule,100% of UHC Fee Schedule,6.46,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,7.45,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.2,22,
THERAPEUTIC PROPHYLACTIC/DX INJECTION SU,1002596,CDM,960,RC,96372,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,15.67,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,22.16,350,,,Fee Schedule,350% of CMS OPPS Rate,15.83,102,,,Fee Schedule,102% of CMS OPPS Rate,50,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.28,100,,,Fee Schedule,100% of Fee Schedule,15.67,100,,,Fee Schedule,100% of Fee Schedule,15.67,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,26.9,100,,,Fee Schedule,100% of UHC Fee Schedule,26.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.67,50,
OFFICE OUTPATIENT NEW 10 MINUTES,1002621,CDM,983,RC,99201,HCPCS,Outpatient,,,140,84,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of fee Schedule,37.9,100,,,Fee Schedule,pays at 100% of fee Schedule,26.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.3,180,,,Fee Schedule,180% of CMS Fee Schedule,37.53,350,,,Fee Schedule,350% of CMS OPPS Rate,26.81,102,,,Fee Schedule,102% of CMS OPPS Rate,56,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.13,100,,,Fee Schedule,100% of Fee Schedule,26.54,100,,,Fee Schedule,100% of Fee Schedule,26.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.02,100,,,Fee Schedule,100% of UHC Fee Schedule,27.02,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,56,
"New patient office or other outpatient visit, typically 10 minutes",1002622,CDM,983,RC,99202,HCPCS,Outpatient,,,237,142.2,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.2,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,68.22,100,,,Fee Schedule,pays at 100% of fee Schedule,68.22,100,,,Fee Schedule,pays at 100% of fee Schedule,49.9,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,63.42,180,,,Fee Schedule,180% of CMS Fee Schedule,70.56,350,,,Fee Schedule,350% of CMS OPPS Rate,50.4,102,,,Fee Schedule,102% of CMS OPPS Rate,89,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.77,100,,,Fee Schedule,100% of Fee Schedule,49.9,100,,,Fee Schedule,100% of Fee Schedule,49.9,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,53.02,100,,,Fee Schedule,100% of UHC Fee Schedule,53.02,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,89,
"New patient office or other outpatient visit, typically 30 min",1002623,CDM,983,RC,99203,HCPCS,Outpatient,,,344,206.4,,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.06,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,101.6,100,,,Fee Schedule,pays at 100% of fee Schedule,101.6,100,,,Fee Schedule,pays at 100% of fee Schedule,75.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.71,180,,,Fee Schedule,180% of CMS Fee Schedule,106.53,350,,,Fee Schedule,350% of CMS OPPS Rate,76.09,102,,,Fee Schedule,102% of CMS OPPS Rate,122,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.43,100,,,Fee Schedule,100% of Fee Schedule,75.33,100,,,Fee Schedule,100% of Fee Schedule,75.33,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,81.81,100,,,Fee Schedule,100% of UHC Fee Schedule,81.81,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,122,
"New patient office of other outpatient visit, typically 45 min",1002624,CDM,960,RC,99204,HCPCS,Outpatient,,,527,316.2,,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,143.92,100,,,Fee Schedule,pays at 100% of fee Schedule,143.92,100,,,Fee Schedule,pays at 100% of fee Schedule,127.33,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,144.75,180,,,Fee Schedule,180% of CMS Fee Schedule,180.07,350,,,Fee Schedule,350% of CMS OPPS Rate,128.62,102,,,Fee Schedule,102% of CMS OPPS Rate,182,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.52,100,,,Fee Schedule,100% of Fee Schedule,127.33,100,,,Fee Schedule,100% of Fee Schedule,127.33,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,121.07,100,,,Fee Schedule,100% of UHC Fee Schedule,121.07,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,182,
"New patient office of other outpatient visit, typically 60 min",1002625,CDM,983,RC,99205,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,183.38,100,,,Fee Schedule,pays at 100% of fee Schedule,183.38,100,,,Fee Schedule,pays at 100% of fee Schedule,166.11,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,192.77,180,,,Fee Schedule,180% of CMS Fee Schedule,234.91,350,,,Fee Schedule,350% of CMS OPPS Rate,167.79,102,,,Fee Schedule,102% of CMS OPPS Rate,229,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.3,100,,,Fee Schedule,100% of Fee Schedule,166.11,100,,,Fee Schedule,100% of Fee Schedule,166.11,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,161.14,100,,,Fee Schedule,100% of UHC Fee Schedule,161.14,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,234.91,
Outpatient visit of established patient not requiring a physician,1002626,CDM,983,RC,99211,HCPCS,Outpatient,,,67,40.2,,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,21.74,100,,,Fee Schedule,pays at 100% of fee Schedule,21.74,100,,,Fee Schedule,pays at 100% of fee Schedule,9.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,12.26,180,,,Fee Schedule,180% of CMS Fee Schedule,12.82,350,,,Fee Schedule,350% of CMS OPPS Rate,9.16,102,,,Fee Schedule,102% of CMS OPPS Rate,27,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.15,100,,,Fee Schedule,100% of Fee Schedule,9.07,100,,,Fee Schedule,100% of Fee Schedule,9.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,10.26,100,,,Fee Schedule,100% of UHC Fee Schedule,10.26,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,27,
Outpatient visit of established patient requiring a physician,1002627,CDM,983,RC,99212,HCPCS,Outpatient,,,138,82.8,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.83,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,39.36,100,,,Fee Schedule,pays at 100% of fee Schedule,39.36,100,,,Fee Schedule,pays at 100% of fee Schedule,25.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,32.75,180,,,Fee Schedule,180% of CMS Fee Schedule,35.59,350,,,Fee Schedule,350% of CMS OPPS Rate,25.42,102,,,Fee Schedule,102% of CMS OPPS Rate,48,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.49,100,,,Fee Schedule,100% of Fee Schedule,25.17,100,,,Fee Schedule,100% of Fee Schedule,25.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,27.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.17,48,
"Established patient office or other outpatient visit, typically 15 minutes",1002628,CDM,983,RC,99213,HCPCS,Outpatient,,,231,138.6,,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.58,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,55.27,100,,,Fee Schedule,pays at 100% of fee Schedule,55.27,100,,,Fee Schedule,pays at 100% of fee Schedule,50.26,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.01,180,,,Fee Schedule,180% of CMS Fee Schedule,71.08,350,,,Fee Schedule,350% of CMS OPPS Rate,50.77,102,,,Fee Schedule,102% of CMS OPPS Rate,68,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.74,100,,,Fee Schedule,100% of Fee Schedule,50.26,100,,,Fee Schedule,100% of Fee Schedule,50.26,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,40.07,100,,,Fee Schedule,100% of UHC Fee Schedule,40.07,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,71.08,
"Established patient office or other outpatient visit, typically 25 minutes",1002629,CDM,983,RC,99214,HCPCS,Outpatient,,,342,205.2,,,,,,Other,Not Separately reimbursable,33.39,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.44,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,86.43,100,,,Fee Schedule,pays at 100% of fee Schedule,86.43,100,,,Fee Schedule,pays at 100% of fee Schedule,77.42,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,79.59,180,,,Fee Schedule,180% of CMS Fee Schedule,109.48,350,,,Fee Schedule,350% of CMS OPPS Rate,78.2,102,,,Fee Schedule,102% of CMS OPPS Rate,105,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.19,100,,,Fee Schedule,100% of Fee Schedule,77.42,100,,,Fee Schedule,100% of Fee Schedule,77.42,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,66.46,100,,,Fee Schedule,100% of UHC Fee Schedule,66.46,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,109.48,
"Established patient office or other outpatient, visit typically 40 minutes",1002630,CDM,983,RC,99215,HCPCS,Outpatient,,,463,277.8,,,,,,Other,Not Separately reimbursable,55.44,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,126.34,100,,,Fee Schedule,pays at 100% of fee Schedule,126.34,100,,,Fee Schedule,pays at 100% of fee Schedule,109.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,127.61,180,,,Fee Schedule,180% of CMS Fee Schedule,154.48,350,,,Fee Schedule,350% of CMS OPPS Rate,110.34,102,,,Fee Schedule,102% of CMS OPPS Rate,166,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.54,100,,,Fee Schedule,100% of Fee Schedule,109.24,100,,,Fee Schedule,100% of Fee Schedule,109.24,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,106.53,100,,,Fee Schedule,100% of UHC Fee Schedule,106.53,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.44,166,
OBSERVATION CARE DISCHARGE MANAGEMENT,1002631,CDM,987,RC,99217,HCPCS,Outpatient,,,237,142.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,95.09,180,,,Fee Schedule,180% of CMS Fee Schedule,100.91,350,,,Fee Schedule,350% of CMS OPPS Rate,72.08,102,,,Fee Schedule,102% of CMS OPPS Rate,131,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.17,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,140.76,100,,,Fee Schedule,100% of UHC Fee Schedule,140.76,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,140.76,
INITIAL OBSERVATION CARE/DAY 30 MINUTES,1002632,CDM,987,RC,99218,HCPCS,Outpatient,,,328,196.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,98.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,91.04,180,,,Fee Schedule,180% of CMS Fee Schedule,139.22,350,,,Fee Schedule,350% of CMS OPPS Rate,99.44,102,,,Fee Schedule,102% of CMS OPPS Rate,129,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,160.51,100,,,Fee Schedule,100% of UHC Fee Schedule,160.51,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,160.51,
INITIAL OBSERVATION CARE/DAY 50 MINUTES,1002633,CDM,987,RC,99219,HCPCS,Outpatient,,,445,267,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,133.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,151.51,180,,,Fee Schedule,180% of CMS Fee Schedule,189.22,350,,,Fee Schedule,350% of CMS OPPS Rate,135.16,102,,,Fee Schedule,102% of CMS OPPS Rate,205,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,241.31,100,,,Fee Schedule,100% of UHC Fee Schedule,241.31,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,241.31,
INITIAL OBSERVATION CARE/DAY 70 MINUTES,1002634,CDM,987,RC,99220,HCPCS,Outpatient,,,608,364.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,182.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.77,180,,,Fee Schedule,180% of CMS Fee Schedule,258.29,350,,,Fee Schedule,350% of CMS OPPS Rate,184.49,102,,,Fee Schedule,102% of CMS OPPS Rate,258,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,334.41,100,,,Fee Schedule,100% of UHC Fee Schedule,334.41,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,205.6,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,334.41,
INITIAL HOSPITAL CARE/DAY 30 MINUTES,1002635,CDM,987,RC,99221,HCPCS,Outpatient,,,333,199.8,,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,100.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,92.06,180,,,Fee Schedule,180% of CMS Fee Schedule,141.93,350,,,Fee Schedule,350% of CMS OPPS Rate,101.38,102,,,Fee Schedule,102% of CMS OPPS Rate,127,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.98,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,163.1,100,,,Fee Schedule,100% of UHC Fee Schedule,163.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,163.1,
INITIAL HOSPITAL CARE/DAY 50 MINUTES,1002636,CDM,987,RC,99222,HCPCS,Outpatient,,,448,268.8,,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,135.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,152.4,180,,,Fee Schedule,180% of CMS Fee Schedule,190.93,350,,,Fee Schedule,350% of CMS OPPS Rate,136.38,102,,,Fee Schedule,102% of CMS OPPS Rate,210,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.21,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,243.12,100,,,Fee Schedule,100% of UHC Fee Schedule,243.12,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,243.12,
INITIAL HOSPITAL CARE/DAY 70 MINUTES,1002637,CDM,987,RC,99223,HCPCS,Outpatient,,,663,397.8,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,199.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,212.21,180,,,Fee Schedule,180% of CMS Fee Schedule,281.51,350,,,Fee Schedule,350% of CMS OPPS Rate,201.08,102,,,Fee Schedule,102% of CMS OPPS Rate,268,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.79,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,347.96,100,,,Fee Schedule,100% of UHC Fee Schedule,347.96,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,347.96,
SBSQ OBSERVATION CARE/DAY 15 MINUTES,1002638,CDM,987,RC,99224,HCPCS,Outpatient,,,131,78.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,39.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,55.4,350,,,Fee Schedule,350% of CMS OPPS Rate,39.57,102,,,Fee Schedule,102% of CMS OPPS Rate,81,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.6,60,,,percent of total billed charges,60% of total billed charges,39.17,100,,,Fee Schedule,100% of Fee Schedule,39.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,72.76,100,,,Fee Schedule,100% of UHC Fee Schedule,72.76,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,81,
SBSQ OBSERVATION CARE/DAY 25 MINUTES,1002639,CDM,987,RC,99225,HCPCS,Outpatient,,,238,142.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,71.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,101.7,350,,,Fee Schedule,350% of CMS OPPS Rate,72.64,102,,,Fee Schedule,102% of CMS OPPS Rate,146,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.8,60,,,percent of total billed charges,60% of total billed charges,71.91,100,,,Fee Schedule,100% of Fee Schedule,71.91,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,133.1,100,,,Fee Schedule,100% of UHC Fee Schedule,133.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.38,146,
SBSQ OBSERVATION CARE/DAY 35 MINUTES,1002640,CDM,987,RC,99226,HCPCS,Outpatient,,,342,205.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,102.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,145.47,350,,,Fee Schedule,350% of CMS OPPS Rate,103.91,102,,,Fee Schedule,102% of CMS OPPS Rate,210,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.2,60,,,percent of total billed charges,60% of total billed charges,102.87,100,,,Fee Schedule,100% of Fee Schedule,102.87,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,191.01,100,,,Fee Schedule,100% of UHC Fee Schedule,191.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.43,210,
SBSQ HOSPITAL CARE/DAY 15 MINUTES,1002641,CDM,987,RC,99231,HCPCS,Outpatient,,,129,77.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,38.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,45.98,180,,,Fee Schedule,180% of CMS Fee Schedule,54.95,350,,,Fee Schedule,350% of CMS OPPS Rate,39.25,102,,,Fee Schedule,102% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,71.74,100,,,Fee Schedule,100% of UHC Fee Schedule,71.74,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.02,71.74,
SBSQ HOSPITAL CARE/DAY 25 MINUTES,1002642,CDM,987,RC,99232,HCPCS,Outpatient,,,238,142.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,71.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.11,180,,,Fee Schedule,180% of CMS Fee Schedule,101.23,350,,,Fee Schedule,350% of CMS OPPS Rate,72.31,102,,,Fee Schedule,102% of CMS OPPS Rate,97,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.72,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.08,100,,,Fee Schedule,100% of UHC Fee Schedule,124.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.57,124.08,
SBSQ HOSPITAL CARE/DAY 35 MINUTES,1002643,CDM,987,RC,99233,HCPCS,Outpatient,,,341,204.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,102.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.85,180,,,Fee Schedule,180% of CMS Fee Schedule,144.73,350,,,Fee Schedule,350% of CMS OPPS Rate,103.38,102,,,Fee Schedule,102% of CMS OPPS Rate,135,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,176.95,100,,,Fee Schedule,100% of UHC Fee Schedule,176.95,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.74,176.95,
OBSERVATION/INPATIENT HOSPITAL CARE 40 M,1002644,CDM,987,RC,99234,HCPCS,Outpatient,,,436,261.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,131.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,183.11,180,,,Fee Schedule,180% of CMS Fee Schedule,185.57,350,,,Fee Schedule,350% of CMS OPPS Rate,132.55,102,,,Fee Schedule,102% of CMS OPPS Rate,240,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.04,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,265.6,100,,,Fee Schedule,100% of UHC Fee Schedule,265.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.22,265.6,
OBSERVATION/INPATIENT HOSPITAL CARE 50 M,1002645,CDM,987,RC,99235,HCPCS,Outpatient,,,553,331.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,166.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,241.57,180,,,Fee Schedule,180% of CMS Fee Schedule,235.56,350,,,Fee Schedule,350% of CMS OPPS Rate,168.26,102,,,Fee Schedule,102% of CMS OPPS Rate,327,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.19,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,344.61,100,,,Fee Schedule,100% of UHC Fee Schedule,344.61,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.58,344.61,
OBSERVATION/INPATIENT HOSPITAL CARE 55 M,1002646,CDM,987,RC,99236,HCPCS,Outpatient,,,713,427.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,214.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,301.39,180,,,Fee Schedule,180% of CMS Fee Schedule,302.69,350,,,Fee Schedule,350% of CMS OPPS Rate,216.21,102,,,Fee Schedule,102% of CMS OPPS Rate,398,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.08,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,435.21,100,,,Fee Schedule,100% of UHC Fee Schedule,435.21,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,292.63,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.05,435.21,
HOSPITAL DISCHARGE DAY MANAGEMENT 30 MIN,1002647,CDM,987,RC,99238,HCPCS,Outpatient,,,237,142.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,94.98,180,,,Fee Schedule,180% of CMS Fee Schedule,100.91,350,,,Fee Schedule,350% of CMS OPPS Rate,72.08,102,,,Fee Schedule,102% of CMS OPPS Rate,131,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.79,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,140.59,100,,,Fee Schedule,100% of UHC Fee Schedule,140.59,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,140.59,
HOSPITAL DISCHARGE DAY MANAGEMENT > 30 M,1002648,CDM,987,RC,99239,HCPCS,Outpatient,,,349,209.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,104.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,129.57,180,,,Fee Schedule,180% of CMS Fee Schedule,147.88,350,,,Fee Schedule,350% of CMS OPPS Rate,105.63,102,,,Fee Schedule,102% of CMS OPPS Rate,166,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.75,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,198.01,100,,,Fee Schedule,100% of UHC Fee Schedule,198.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.78,198.01,
"Patient office consultation, typically 40 min",1002651,CDM,983,RC,99243,HCPCS,Outpatient,,,450,270,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,127.85,100,,,Fee Schedule,pays at 100% of fee Schedule,127.85,100,,,Fee Schedule,pays at 100% of fee Schedule,94.25,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,126.85,180,,,Fee Schedule,180% of CMS Fee Schedule,133.28,350,,,Fee Schedule,350% of CMS OPPS Rate,95.2,102,,,Fee Schedule,102% of CMS OPPS Rate,180,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.94,100,,,Fee Schedule,100% of Fee Schedule,94.25,100,,,Fee Schedule,100% of Fee Schedule,94.25,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,106.36,100,,,Fee Schedule,100% of UHC Fee Schedule,106.36,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,180,
"Patient office consultation, typically 60 min",1002652,CDM,983,RC,99244,HCPCS,Outpatient,,,547,328.2,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,181.6,100,,,Fee Schedule,pays at 100% of fee Schedule,181.6,100,,,Fee Schedule,pays at 100% of fee Schedule,151.53,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,187.21,180,,,Fee Schedule,180% of CMS Fee Schedule,214.28,350,,,Fee Schedule,350% of CMS OPPS Rate,153.06,102,,,Fee Schedule,102% of CMS OPPS Rate,252,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.96,100,,,Fee Schedule,100% of Fee Schedule,151.53,100,,,Fee Schedule,100% of Fee Schedule,151.53,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,156.62,100,,,Fee Schedule,100% of UHC Fee Schedule,156.62,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,252,
OFFICE CONSULT LEVEL V,1002653,CDM,983,RC,99245,HCPCS,Outpatient,,,668,400.8,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,234.8,100,,,Fee Schedule,pays at 100% of fee Schedule,234.8,100,,,Fee Schedule,pays at 100% of fee Schedule,187.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,248.96,180,,,Fee Schedule,180% of CMS Fee Schedule,265.29,350,,,Fee Schedule,350% of CMS OPPS Rate,189.49,102,,,Fee Schedule,102% of CMS OPPS Rate,341,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.21,100,,,Fee Schedule,100% of Fee Schedule,187.6,100,,,Fee Schedule,100% of Fee Schedule,187.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,208.3,100,,,Fee Schedule,100% of UHC Fee Schedule,208.3,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,341,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 2,1002655,CDM,988,RC,99251,HCPCS,Outpatient,,,158,94.8,,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,48.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,48.61,180,,,Fee Schedule,180% of CMS Fee Schedule,68.4,350,,,Fee Schedule,350% of CMS OPPS Rate,48.86,102,,,Fee Schedule,102% of CMS OPPS Rate,92,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.2,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,40.75,100,,,Fee Schedule,100% of UHC Fee Schedule,40.75,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,92,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 4,1002656,CDM,988,RC,99252,HCPCS,Outpatient,,,215,129,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,77.85,100,,,Fee Schedule,pays at 100% of fee Schedule,77.85,100,,,Fee Schedule,pays at 100% of fee Schedule,73.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,97.55,180,,,Fee Schedule,180% of CMS Fee Schedule,104.38,350,,,Fee Schedule,350% of CMS OPPS Rate,74.56,102,,,Fee Schedule,102% of CMS OPPS Rate,140,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.59,100,,,Fee Schedule,100% of Fee Schedule,73.82,100,,,Fee Schedule,100% of Fee Schedule,73.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,145.1,100,,,Fee Schedule,100% of UHC Fee Schedule,145.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,145.1,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 5,1002657,CDM,988,RC,99253,HCPCS,Outpatient,,,290,174,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,113.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,133.29,180,,,Fee Schedule,180% of CMS Fee Schedule,160.59,350,,,Fee Schedule,350% of CMS OPPS Rate,114.71,102,,,Fee Schedule,102% of CMS OPPS Rate,185,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.57,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,209.03,100,,,Fee Schedule,100% of UHC Fee Schedule,209.03,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,209.03,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 8,1002658,CDM,988,RC,99254,HCPCS,Outpatient,,,420,252,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.74,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,152.21,100,,,Fee Schedule,pays at 100% of fee Schedule,152.21,100,,,Fee Schedule,pays at 100% of fee Schedule,164.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,191.39,180,,,Fee Schedule,180% of CMS Fee Schedule,233.14,350,,,Fee Schedule,350% of CMS OPPS Rate,166.53,102,,,Fee Schedule,102% of CMS OPPS Rate,254,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.07,100,,,Fee Schedule,100% of Fee Schedule,164.86,100,,,Fee Schedule,100% of Fee Schedule,164.86,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,301.45,100,,,Fee Schedule,100% of UHC Fee Schedule,301.45,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,301.45,
INITIAL INPATIENT CONSULT NEW/ESTAB PT 1,1002659,CDM,988,RC,99255,HCPCS,Outpatient,,,575,345,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,198.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,263.89,180,,,Fee Schedule,180% of CMS Fee Schedule,280.78,350,,,Fee Schedule,350% of CMS OPPS Rate,200.56,102,,,Fee Schedule,102% of CMS OPPS Rate,343,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.17,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,390.94,100,,,Fee Schedule,100% of UHC Fee Schedule,390.94,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,390.94,
CRITICAL CARE ILL/INJURED PATIENT INIT 3,1002665,CDM,983,RC,99291,HCPCS,Outpatient,,,886,531.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,280.99,180,,,Fee Schedule,180% of CMS Fee Schedule,312.84,350,,,Fee Schedule,350% of CMS OPPS Rate,223.46,102,,,Fee Schedule,102% of CMS OPPS Rate,392,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.12,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,424.54,100,,,Fee Schedule,100% of UHC Fee Schedule,424.54,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221,424.54,
CRITICAL CARE ILL/INJURED PATIENT ADDL 3,1002666,CDM,983,RC,99292,HCPCS,Outpatient,,,401,240.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.55,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,110.49,100,,,Fee Schedule,pays at 100% of fee Schedule,110.49,100,,,Fee Schedule,pays at 100% of fee Schedule,110.99,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,141.04,180,,,Fee Schedule,180% of CMS Fee Schedule,156.95,350,,,Fee Schedule,350% of CMS OPPS Rate,112.11,102,,,Fee Schedule,102% of CMS OPPS Rate,191,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.47,100,,,Fee Schedule,100% of Fee Schedule,110.99,100,,,Fee Schedule,100% of Fee Schedule,110.99,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,213.08,100,,,Fee Schedule,100% of UHC Fee Schedule,213.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.49,213.08,
SBSQ NURSING FACIL CARE/DAY MINOR COMPLJ,1002671,CDM,960,RC,99308,HCPCS,Outpatient,,,224,134.4,,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,66.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,75.52,180,,,Fee Schedule,180% of CMS Fee Schedule,94.7,350,,,Fee Schedule,350% of CMS OPPS Rate,67.64,102,,,Fee Schedule,102% of CMS OPPS Rate,140,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.23,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,120.61,100,,,Fee Schedule,100% of UHC Fee Schedule,120.61,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.97,140,
SBSQ NURSING FACIL CARE/DAY NEW PROBLEM,1002672,CDM,960,RC,99309,HCPCS,Outpatient,,,296,177.6,,,,,,Other,Not Separately reimbursable,85,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.61,100,,,Fee Schedule,pays at 100% of fee Schedule,84.61,100,,,Fee Schedule,pays at 100% of fee Schedule,89.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,106.57,180,,,Fee Schedule,180% of CMS Fee Schedule,126.03,350,,,Fee Schedule,350% of CMS OPPS Rate,90.02,102,,,Fee Schedule,102% of CMS OPPS Rate,184,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.64,100,,,Fee Schedule,100% of Fee Schedule,89.12,100,,,Fee Schedule,100% of Fee Schedule,89.12,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,165.59,100,,,Fee Schedule,100% of UHC Fee Schedule,165.59,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.61,184,
SBSQ NURS FACIL CARE/DAY UNSTABL/NEW PRO,1002673,CDM,960,RC,99310,HCPCS,Outpatient,,,440,264,,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.25,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105.96,100,,,Fee Schedule,pays at 100% of fee Schedule,105.96,100,,,Fee Schedule,pays at 100% of fee Schedule,132.15,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,133.45,180,,,Fee Schedule,180% of CMS Fee Schedule,186.86,350,,,Fee Schedule,350% of CMS OPPS Rate,133.47,102,,,Fee Schedule,102% of CMS OPPS Rate,273,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.04,100,,,Fee Schedule,100% of Fee Schedule,132.15,100,,,Fee Schedule,100% of Fee Schedule,132.15,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,225.05,100,,,Fee Schedule,100% of UHC Fee Schedule,225.05,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,82.17,100,,,Fee Schedule,100% of LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.17,273,
PROLONGED SERVICE I/P REQ UNIT/FLOOR TIM,1002690,CDM,983,RC,99356,HCPCS,Outpatient,,,300,180,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.19,100,,,Fee Schedule,pays at 100% of fee Schedule,97.19,100,,,Fee Schedule,pays at 100% of fee Schedule,90.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,122.51,180,,,Fee Schedule,180% of CMS Fee Schedule,127.83,350,,,Fee Schedule,350% of CMS OPPS Rate,91.31,102,,,Fee Schedule,102% of CMS OPPS Rate,182,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.81,100,,,Fee Schedule,100% of Fee Schedule,90.4,100,,,Fee Schedule,100% of Fee Schedule,90.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,179.82,100,,,Fee Schedule,100% of UHC Fee Schedule,179.82,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.4,182,
PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA,1002691,CDM,983,RC,99357,HCPCS,Outpatient,,,301,180.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.76,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,97.55,100,,,Fee Schedule,pays at 100% of fee Schedule,97.55,100,,,Fee Schedule,pays at 100% of fee Schedule,90.71,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.52,180,,,Fee Schedule,180% of CMS Fee Schedule,128.28,350,,,Fee Schedule,350% of CMS OPPS Rate,91.63,102,,,Fee Schedule,102% of CMS OPPS Rate,183,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.54,100,,,Fee Schedule,100% of Fee Schedule,90.71,100,,,Fee Schedule,100% of Fee Schedule,90.71,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,103.15,100,,,Fee Schedule,100% of UHC Fee Schedule,103.15,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.71,183,
PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE,1002692,CDM,960,RC,99358,HCPCS,Outpatient,,,364,218.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,156.07,100,,,Fee Schedule,pays at 100% of fee Schedule,156.07,100,,,Fee Schedule,pays at 100% of fee Schedule,109.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,155.3,350,,,Fee Schedule,350% of CMS OPPS Rate,110.93,102,,,Fee Schedule,102% of CMS OPPS Rate,190,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.4,60,,,percent of total billed charges,60% of total billed charges,109.82,100,,,Fee Schedule,100% of Fee Schedule,109.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,94.29,100,,,Fee Schedule,100% of UHC Fee Schedule,94.29,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.29,218.4,
New preventative visit in new patients 12-17 years old,1002697,CDM,983,RC,99384,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,100.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.05,180,,,Fee Schedule,180% of CMS Fee Schedule,142.18,350,,,Fee Schedule,350% of CMS OPPS Rate,101.56,102,,,Fee Schedule,102% of CMS OPPS Rate,206,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,100.54,100,,,Fee Schedule,100% of Fee Schedule,100.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,141.34,100,,,Fee Schedule,100% of UHC Fee Schedule,141.34,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,399,
Initial new patient preventive medicine evaluation (18?9 years),1002698,CDM,983,RC,99385,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.35,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,123.05,100,,,Fee Schedule,pays at 100% of fee Schedule,96.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.05,180,,,Fee Schedule,180% of CMS Fee Schedule,136.19,350,,,Fee Schedule,350% of CMS OPPS Rate,97.28,102,,,Fee Schedule,102% of CMS OPPS Rate,198,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,96.31,100,,,Fee Schedule,100% of Fee Schedule,96.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,137.7,100,,,Fee Schedule,100% of UHC Fee Schedule,137.7,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.35,399,
Initial new patient preventive medicine evaluation (40?4 years),1002699,CDM,983,RC,99386,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.39,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,145.04,100,,,Fee Schedule,pays at 100% of fee Schedule,145.04,100,,,Fee Schedule,pays at 100% of fee Schedule,117.29,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,136.02,180,,,Fee Schedule,180% of CMS Fee Schedule,165.86,350,,,Fee Schedule,350% of CMS OPPS Rate,118.47,102,,,Fee Schedule,102% of CMS OPPS Rate,240,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,117.29,100,,,Fee Schedule,100% of Fee Schedule,117.29,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,168.06,100,,,Fee Schedule,100% of UHC Fee Schedule,168.06,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.39,399,
Initial visit for new patients 65 and older years old,1002700,CDM,983,RC,99387,HCPCS,Outpatient,,,665,399,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.41,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,157.3,100,,,Fee Schedule,pays at 100% of fee Schedule,157.3,100,,,Fee Schedule,pays at 100% of fee Schedule,126,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,148.72,180,,,Fee Schedule,180% of CMS Fee Schedule,178.18,350,,,Fee Schedule,350% of CMS OPPS Rate,127.27,102,,,Fee Schedule,102% of CMS OPPS Rate,258,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399,60,,,percent of total billed charges,60% of total billed charges,126,100,,,Fee Schedule,100% of Fee Schedule,126,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,181.8,100,,,Fee Schedule,100% of UHC Fee Schedule,181.8,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.41,399,
Periodic primary re-evaluation for an established infant patient,1002701,CDM,983,RC,99391,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,81.55,100,,,Fee Schedule,pays at 100% of fee Schedule,81.55,100,,,Fee Schedule,pays at 100% of fee Schedule,69.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,73.88,180,,,Fee Schedule,180% of CMS Fee Schedule,97.68,350,,,Fee Schedule,350% of CMS OPPS Rate,69.77,102,,,Fee Schedule,102% of CMS OPPS Rate,147,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,69.07,100,,,Fee Schedule,100% of Fee Schedule,69.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of UHC Fee Schedule,95.9,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.02,210,
New preventative visit in new patients 12-17 years old,1002704,CDM,983,RC,99394,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.72,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,100.21,100,,,Fee Schedule,pays at 100% of fee Schedule,100.21,100,,,Fee Schedule,pays at 100% of fee Schedule,85.82,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.32,180,,,Fee Schedule,180% of CMS Fee Schedule,121.37,350,,,Fee Schedule,350% of CMS OPPS Rate,86.69,102,,,Fee Schedule,102% of CMS OPPS Rate,174,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,85.82,100,,,Fee Schedule,100% of Fee Schedule,85.82,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,122.38,100,,,Fee Schedule,100% of UHC Fee Schedule,122.38,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.72,210,
Established patient periodic preventive medicine examination age 18-39 years,1002705,CDM,983,RC,99395,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,101.3,100,,,Fee Schedule,pays at 100% of fee Schedule,101.3,100,,,Fee Schedule,pays at 100% of fee Schedule,88.24,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,98.32,180,,,Fee Schedule,180% of CMS Fee Schedule,124.78,350,,,Fee Schedule,350% of CMS OPPS Rate,89.13,102,,,Fee Schedule,102% of CMS OPPS Rate,179,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,88.24,100,,,Fee Schedule,100% of Fee Schedule,88.24,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,124.45,100,,,Fee Schedule,100% of UHC Fee Schedule,124.45,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.03,210,
Established patient periodic preventive medicine examination age 40-64 years,1002706,CDM,983,RC,99396,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.36,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,112.13,100,,,Fee Schedule,pays at 100% of fee Schedule,112.13,100,,,Fee Schedule,pays at 100% of fee Schedule,95.59,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,111.05,180,,,Fee Schedule,180% of CMS Fee Schedule,135.18,350,,,Fee Schedule,350% of CMS OPPS Rate,96.56,102,,,Fee Schedule,102% of CMS OPPS Rate,255,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,95.59,100,,,Fee Schedule,100% of Fee Schedule,95.59,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,137.09,100,,,Fee Schedule,100% of UHC Fee Schedule,137.09,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.36,255,
Periodic primary re-evaluation for an established patient 65 and older,1002707,CDM,983,RC,99397,HCPCS,Outpatient,,,350,210,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,123.66,100,,,Fee Schedule,pays at 100% of fee Schedule,123.66,100,,,Fee Schedule,pays at 100% of fee Schedule,100.54,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,123.75,180,,,Fee Schedule,180% of CMS Fee Schedule,142.18,350,,,Fee Schedule,350% of CMS OPPS Rate,101.56,102,,,Fee Schedule,102% of CMS OPPS Rate,206,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,60,,,percent of total billed charges,60% of total billed charges,100.54,100,,,Fee Schedule,100% of Fee Schedule,100.54,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,147.6,100,,,Fee Schedule,100% of UHC Fee Schedule,147.6,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.4,210,
PREVENTIVE MEDICINE COUNSELING;  30 MIN,1002708,CDM,983,RC,99402,HCPCS,Outpatient,,,200.31,120.19,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.86,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,73.53,100,,,Fee Schedule,pays at 100% of fee Schedule,73.53,100,,,Fee Schedule,pays at 100% of fee Schedule,49.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,69.73,180,,,Fee Schedule,180% of CMS Fee Schedule,70.08,350,,,Fee Schedule,350% of CMS OPPS Rate,50.06,102,,,Fee Schedule,102% of CMS OPPS Rate,101,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.19,60,,,percent of total billed charges,60% of total billed charges,49.56,100,,,Fee Schedule,100% of Fee Schedule,49.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,77,100,,,Fee Schedule,100% of UHC Fee Schedule,77,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.56,120.19,
TOBACCO USE CESSATION INTERMEDIATE 3-10,1002709,CDM,983,RC,99406,HCPCS,Outpatient,,,47,28.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.59,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of fee Schedule,12.87,100,,,Fee Schedule,pays at 100% of fee Schedule,12.27,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,17.35,350,,,Fee Schedule,350% of CMS OPPS Rate,12.39,102,,,Fee Schedule,102% of CMS OPPS Rate,25,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.58,100,,,Fee Schedule,100% of Fee Schedule,12.27,100,,,Fee Schedule,100% of Fee Schedule,12.27,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,25.32,100,,,Fee Schedule,100% of UHC Fee Schedule,25.32,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.27,25.32,
TOBACCO USE CESSATION INTENSIVE >10 MINU,1002710,CDM,983,RC,99407,HCPCS,Outpatient,,,91,54.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.23,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,25.39,100,,,Fee Schedule,pays at 100% of fee Schedule,25.39,100,,,Fee Schedule,pays at 100% of fee Schedule,25.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,36.15,350,,,Fee Schedule,350% of CMS OPPS Rate,25.82,102,,,Fee Schedule,102% of CMS OPPS Rate,52,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,100,,,Fee Schedule,100% of Fee Schedule,25.56,100,,,Fee Schedule,100% of Fee Schedule,25.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,50.47,100,,,Fee Schedule,100% of UHC Fee Schedule,50.47,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.39,52,
ALCOHOL/SUBSTANCE SCREEN & INTERVENTION,1002711,CDM,983,RC,99409,HCPCS,Outpatient,,,214.38,128.63,,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.34,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,61.38,100,,,Fee Schedule,pays at 100% of fee Schedule,61.38,100,,,Fee Schedule,pays at 100% of fee Schedule,65.63,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,92.81,350,,,Fee Schedule,350% of CMS OPPS Rate,66.29,102,,,Fee Schedule,102% of CMS OPPS Rate,134,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.63,60,,,percent of total billed charges,60% of total billed charges,65.63,100,,,Fee Schedule,100% of Fee Schedule,65.63,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,69.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,134,
"Physician telephone patient service, 11-20 minutes of medical discussion",1002714,CDM,960,RC,99442,HCPCS,Outpatient,,,228.45,137.07,,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.8,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,24.38,100,,,Fee Schedule,pays at 100% of fee Schedule,24.38,100,,,Fee Schedule,pays at 100% of fee Schedule,25.14,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,35.55,350,,,Fee Schedule,350% of CMS OPPS Rate,25.39,102,,,Fee Schedule,102% of CMS OPPS Rate,51,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.07,60,,,percent of total billed charges,60% of total billed charges,25.14,100,,,Fee Schedule,100% of Fee Schedule,25.14,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,27.25,100,,,Fee Schedule,100% of UHC Fee Schedule,27.25,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,137.07,
"Physician telephone patient service, 21-30 minutes of medical discussion",1002715,CDM,960,RC,99443,HCPCS,Outpatient,,,331.29,198.77,,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.21,100,,,Fee Schedule,pays at 100% of fee Schedule,36.21,100,,,Fee Schedule,pays at 100% of fee Schedule,37.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,53.24,350,,,Fee Schedule,350% of CMS OPPS Rate,38.03,102,,,Fee Schedule,102% of CMS OPPS Rate,77,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.77,60,,,percent of total billed charges,60% of total billed charges,37.65,100,,,Fee Schedule,100% of Fee Schedule,37.65,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,39.73,100,,,Fee Schedule,100% of UHC Fee Schedule,39.73,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25,198.77,
ADVANCE CARE PLANNING FIRST 30 MINS,1002728,CDM,983,RC,99497,HCPCS,Outpatient,,,274,164.4,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,50,,,percent of total billed charges,pays at 50% of total billed charges,150.7,55,,,percent of total billed charges,55% of total billed charges,150.7,55,,,percent of total billed charges,55% of total billed charges,77.73,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,109.93,350,,,Fee Schedule,350% of CMS OPPS Rate,78.52,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.4,60,,,percent of total billed charges,60% of total billed charges,77.73,100,,,Fee Schedule,100% of Fee Schedule,77.73,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,83.18,100,,,Fee Schedule,100% of UHC Fee Schedule,83.18,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.02,164.4,
ADVANCE CARE PLANNING EA ADDL 30 MINS,1002729,CDM,983,RC,99498,HCPCS,Outpatient,,,243,145.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.89,50,,,percent of total billed charges,pays at 50% of total billed charges,133.65,55,,,percent of total billed charges,55% of total billed charges,133.65,55,,,percent of total billed charges,55% of total billed charges,73.1,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,103.38,350,,,Fee Schedule,350% of CMS OPPS Rate,73.84,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.8,60,,,percent of total billed charges,60% of total billed charges,73.1,100,,,Fee Schedule,100% of Fee Schedule,73.1,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,73.3,100,,,Fee Schedule,100% of UHC Fee Schedule,73.3,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.89,145.8,
EXT ECG > 48HR TO 21 DAY RCRD W/CONECT I,1002731,CDM,983,RC,0296T,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.18,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,21.31,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,25.83,350,,,Fee Schedule,350% of CMS OPPS Rate,18.45,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,60,,,percent of total billed charges,60% of total billed charges,21.31,100,,,Fee Schedule,100% of Fee Schedule,21.31,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.45,43.18,
EXT ECG > 48HR TO 21 DAY REVIEW AND INTE,1002732,CDM,983,RC,0298T,HCPCS,Outpatient,,,83,49.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,45.65,55,,,percent of total billed charges,55% of total billed charges,45.65,55,,,percent of total billed charges,55% of total billed charges,26.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,35.73,350,,,Fee Schedule,350% of CMS OPPS Rate,25.52,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.8,60,,,percent of total billed charges,60% of total billed charges,26.06,100,,,Fee Schedule,100% of Fee Schedule,26.06,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.52,49.8,
CERVIX/VAGINAL CA SCREEN,1002757,CDM,971,RC,G0101,HCPCS,Outpatient,,,121,72.6,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,66.55,55,,,percent of total billed charges,55% of total billed charges,66.55,55,,,percent of total billed charges,55% of total billed charges,27.06,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,41.96,180,,,Fee Schedule,180% of CMS Fee Schedule,52.58,350,,,Fee Schedule,350% of CMS OPPS Rate,37.56,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,100% of Fee Schedule,27.06,100,,,Fee Schedule,100% of Fee Schedule,27.06,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,61.81,100,,,Fee Schedule,100% of UHC Fee Schedule,61.81,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.06,66.55,
TRIMMING OF DYSTROPHIC NAIL(S),1002763,CDM,983,RC,G0127,HCPCS,Outpatient,,,75,45,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,41.25,55,,,percent of total billed charges,55% of total billed charges,41.25,55,,,percent of total billed charges,55% of total billed charges,7.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,16.36,180,,,Fee Schedule,180% of CMS Fee Schedule,10.98,350,,,Fee Schedule,350% of CMS OPPS Rate,7.84,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.44,100,,,Fee Schedule,100% of Fee Schedule,7.76,100,,,Fee Schedule,100% of Fee Schedule,7.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,22.01,100,,,Fee Schedule,100% of UHC Fee Schedule,22.01,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.76,41.25,
INITIAL PREVENTIVE PHYSICAL EXAMINATION,1002770,CDM,983,RC,G0402,HCPCS,Outpatient,,,532,319.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,292.6,55,,,percent of total billed charges,55% of total billed charges,292.6,55,,,percent of total billed charges,55% of total billed charges,124.76,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,176.43,350,,,Fee Schedule,350% of CMS OPPS Rate,126.02,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.66,100,,,Fee Schedule,100% of Fee Schedule,124.76,100,,,Fee Schedule,100% of Fee Schedule,124.76,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,265.96,100,,,Fee Schedule,100% of UHC Fee Schedule,265.96,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.76,292.6,
ANNUAL WELLNESS VISIT;  INITIAL VISIT,1002776,CDM,983,RC,G0438,HCPCS,Outpatient,,,548,328.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,301.4,55,,,percent of total billed charges,55% of total billed charges,301.4,55,,,percent of total billed charges,55% of total billed charges,164.75,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,232.97,350,,,Fee Schedule,350% of CMS OPPS Rate,166.41,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.8,60,,,percent of total billed charges,60% of total billed charges,164.75,100,,,Fee Schedule,100% of Fee Schedule,164.75,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,304.09,100,,,Fee Schedule,100% of UHC Fee Schedule,304.09,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,328.8,
ANNUAL WELLNESS VISIT  SUBSEQUENT VISIT,1002777,CDM,983,RC,G0439,HCPCS,Outpatient,,,370,222,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.68,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,203.5,55,,,percent of total billed charges,55% of total billed charges,203.5,55,,,percent of total billed charges,55% of total billed charges,110.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,156.91,350,,,Fee Schedule,350% of CMS OPPS Rate,112.08,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222,60,,,percent of total billed charges,60% of total billed charges,110.96,100,,,Fee Schedule,100% of Fee Schedule,110.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,205.1,100,,,Fee Schedule,100% of UHC Fee Schedule,205.1,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.68,222,
OBTAINING SCREEN PAP SMEAR; PREP/CONVY T,1002870,CDM,960,RC,Q0091,HCPCS,Outpatient,,,138,82.8,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.9,55,,,percent of total billed charges,55% of total billed charges,75.9,55,,,percent of total billed charges,55% of total billed charges,19.34,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,34.76,180,,,Fee Schedule,180% of CMS Fee Schedule,57.79,350,,,Fee Schedule,350% of CMS OPPS Rate,41.28,102,,,Fee Schedule,102% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.58,100,,,Fee Schedule,100% of Fee Schedule,19.34,100,,,Fee Schedule,100% of Fee Schedule,19.34,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,29.08,100,,,Fee Schedule,100% of UHC Fee Schedule,29.08,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.34,75.9,
"CGM PROFESSIONAL ANALYSIS, INTERP AND RP",1003000,CDM,960,RC,95251,HCPCS,Outpatient,,,107,64.2,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.49,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.85,55,,,percent of total billed charges,55% of total billed charges,58.85,55,,,percent of total billed charges,55% of total billed charges,35.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,47.88,180,,,Fee Schedule,180% of CMS Fee Schedule,49.83,350,,,Fee Schedule,350% of CMS OPPS Rate,35.59,102,,,Fee Schedule,102% of CMS OPPS Rate,89,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.23,100,,,Fee Schedule,100% of Fee Schedule,35.23,100,,,Fee Schedule,100% of Fee Schedule,35.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,25.07,100,,,Fee Schedule,100% of UHC Fee Schedule,25.07,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.07,89,
EKG INTERPRET AND REPORT,3788030E,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
EKG INTERPRET AND REPORT,3788060E,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
EKG INTERPRET AND REPORT,4111101,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
EKG INTERPRET AND REPORT,4111102,CDM,985,RC,93010,HCPCS,Outpatient,,,60,36,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33,55,,,percent of total billed charges,55% of total billed charges,33,55,,,percent of total billed charges,55% of total billed charges,8.4,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,15.77,180,,,Fee Schedule,180% of CMS Fee Schedule,11.87,350,,,Fee Schedule,350% of CMS OPPS Rate,8.48,102,,,Fee Schedule,102% of CMS OPPS Rate,24,100,,,Fee Schedule,100% of Fee Schedule rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.91,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,8.4,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,16.99,100,,,Fee Schedule,100% of UHC Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.4,33,
INITIAL HOSPITAL CARE PER DAY,7960001,CDM,985,RC,99221,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.33,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,72.57,100,,,Fee Schedule,pays at 100% of fee Schedule,100.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.98,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,100.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.5,127,
INITIAL HOSPITAL CARE PER DAY,7960002,CDM,985,RC,99222,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.87,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,120.87,100,,,Fee Schedule,pays at 100% of fee Schedule,135.02,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.21,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,135.02,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,210,
INITIAL HOSPITAL CARE PER DAY,7960003,CDM,985,RC,99223,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.37,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,168.22,100,,,Fee Schedule,pays at 100% of fee Schedule,199.07,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.79,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,199.07,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,268,
SUBSEQUENT HOSPITAL CARE PER DAY,7960004,CDM,985,RC,99231,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.88,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,36.02,100,,,Fee Schedule,pays at 100% of fee Schedule,38.86,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,38.86,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.02,66,
SUBSEQUENT HOSPITAL CARE PER DAY,7960005,CDM,985,RC,99232,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.02,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,59.57,100,,,Fee Schedule,pays at 100% of fee Schedule,71.6,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.72,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,71.6,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.57,97,
SUBSEQUENT HOSPITAL CARE PER DAY,7960006,CDM,985,RC,99233,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,84.74,100,,,Fee Schedule,pays at 100% of fee Schedule,102.35,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.52,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,102.35,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.74,135,
DISCHARGE HOSPITAL CARE < 30 MINUTES,7960007,CDM,985,RC,99238,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.78,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,75.4,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.79,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,131,
DISCHARGE HOSPITAL CARE > 30 MINUTES,7960008,CDM,985,RC,99239,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.96,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,102.78,100,,,Fee Schedule,pays at 100% of fee Schedule,104.57,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.75,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,104.57,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.78,166,
OBSV HOSPITAL CARE A&D SAME DAY,7960009,CDM,985,RC,99234,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.3,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,149.23,100,,,Fee Schedule,pays at 100% of fee Schedule,131.22,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.04,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,131.22,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.22,240,
OBSV HOSPITAL CARE A&D SAME DAY,7960010,CDM,985,RC,99235,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.26,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,196.66,100,,,Fee Schedule,pays at 100% of fee Schedule,166.58,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.19,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,166.58,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.58,327,
OBSV HOSPITAL CARE A&D SAME DAY,7960011,CDM,985,RC,99236,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.73,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,245.35,100,,,Fee Schedule,pays at 100% of fee Schedule,214.05,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.08,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,214.05,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.05,398,
OBSERVATION INITIAL HOSPITAL CARE,7960012,CDM,985,RC,99218,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.24,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,71.85,100,,,Fee Schedule,pays at 100% of fee Schedule,98.45,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,98.45,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.09,129,
OBSERVATION INITIAL HOSPITAL CARE,7960013,CDM,985,RC,99219,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,120.14,100,,,Fee Schedule,pays at 100% of fee Schedule,133.81,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,133.81,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.78,205,
OBSERVATION INITIAL HOSPITAL CARE,7960014,CDM,985,RC,99220,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.97,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,168.3,100,,,Fee Schedule,pays at 100% of fee Schedule,182.65,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,182.65,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.16,258,
OBSERVATION DISCHARGE HOSPITAL CARE,7960015,CDM,985,RC,99217,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.22,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,75.48,100,,,Fee Schedule,pays at 100% of fee Schedule,71.36,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.17,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,71.36,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.36,131,
OBSV SUBSEQUENT HOSPITAL CARE PER DAY,7960016,CDM,985,RC,99224,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.52,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,33.1,100,,,Fee Schedule,pays at 100% of fee Schedule,39.17,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.17,100,,,Fee Schedule,100% of Fee Schedule,39.17,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.1,81,
OBSV SUBSEQUENT HOSPITAL CARE PER DAY,7960017,CDM,985,RC,99225,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.67,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,58.38,100,,,Fee Schedule,pays at 100% of fee Schedule,71.91,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,100,,,Fee Schedule,100% of Fee Schedule,71.91,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.38,146,
OBSV SUBSEQUENT HOSPITAL CARE PER DAY,7960018,CDM,985,RC,99226,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.21,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,87.43,100,,,Fee Schedule,pays at 100% of fee Schedule,102.87,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.87,100,,,Fee Schedule,100% of Fee Schedule,102.87,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.43,210,
"Emergency department visit, moderately severe problem",7960019,CDM,985,RC,99283,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,165,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,67.59,100,,,Fee Schedule,pays at 100% of fee Schedule,67.59,100,,,Fee Schedule,pays at 100% of fee Schedule,62.12,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.66,100,,,Fee Schedule,100% of Fee Schedule,62.12,100,,,Fee Schedule,100% of Fee Schedule,62.12,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.12,165,
INPATIENT HOSPITAL CONSULT BRIEF,7960020,CDM,985,RC,99251,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.63,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,38.92,100,,,Fee Schedule,pays at 100% of fee Schedule,48.37,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.2,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,48.37,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,92,
INPATIENT HOSPITAL CONSULT COMPREHENSIVE,7960021,CDM,985,RC,99255,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.75,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,209.36,100,,,Fee Schedule,pays at 100% of fee Schedule,198.55,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.17,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,198.55,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,343,
INPATIENT HOSPITAL CONSULT INTERMEDIATE,7960022,CDM,985,RC,99253,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,66.15,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.1,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,105.75,100,,,Fee Schedule,pays at 100% of fee Schedule,113.56,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.57,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,113.56,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.15,185,
HOSPITAL CRITICAL CARE EVAL,7960023,CDM,985,RC,99291,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.32,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221,100,,,Fee Schedule,pays at 100% of fee Schedule,221.23,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.12,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,221.23,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221,392,
SUBSEQUENT NURSING HOME HOSPITAL CARE,7960024,CDM,985,RC,99308,HCPCS,Outpatient,,,,,,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% OF LA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.03,100,,,Fee Schedule,pays at 100% of BCBS Fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,59.97,100,,,Fee Schedule,pays at 100% of fee Schedule,66.96,100,,,Fee Schedule,pays at 100% of CMS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.23,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,66.96,100,,,Fee Schedule,100% of Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.97,140,
2N REHAB ROOM,3010002,CDM,118,RC,,,Inpatient,,,900,540,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,675,100,,,per diem,pays based on per day rate,675,100,,,per diem,pays based on per day rate,450,50,,,percent of total billed charges,50% of total charges,720,80,,,percent of total billed charges,80% of total charges,540,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,598.4,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,45,,,percent of total billed charges,45% of total charges,720,80,,,percent of total billed charges,80% of total charges,1092,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1485,100,,,per diem,pays based on per day rate,630,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,900,100,,,percent of total billed charges,100% of total charges,704,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,1485,
2T HEMATOLOGY ONCOLOGY ROOM,3020002,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
3T SURGICAL ROOM,3030001,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
3T SURGICAL ICU ROOM,3030002,CDM,200,RC,,,Inpatient,,,4500,2700,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1550,100,,,per diem,pays based on per day rate,3375,100,,,per diem,pays based on per day rate,2250,50,,,percent of total billed charges,50% of total charges,3600,80,,,percent of total billed charges,80% of total charges,2700,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,3825,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,2025,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,3281,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,3150,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4500,100,,,percent of total billed charges,100% of total charges,3825,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1211.29,4500,
3T SURGICAL ICU TRANSITIONAL ROOM,3030004,CDM,206,RC,,,Inpatient,,,1300,780,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,975,100,,,per diem,pays based on per day rate,650,50,,,percent of total billed charges,50% of total charges,1040,80,,,percent of total billed charges,80% of total charges,780,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1105,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,585,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,910,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1300,100,,,percent of total billed charges,100% of total charges,1105,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,585,4273,
ICU ROOM & BOARD- TRAUMA,3030110,CDM,208,RC,,,Inpatient,,,5500,3300,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1550,100,,,per diem,pays based on per day rate,4125,100,,,per diem,pays based on per day rate,2750,50,,,percent of total billed charges,50% of total charges,4400,80,,,percent of total billed charges,80% of total charges,3300,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,4675,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,2475,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,3850,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,5500,100,,,percent of total billed charges,100% of total charges,4675,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1211.29,5500,
4 TOWER ADOLESCENT ROOM,3040002,CDM,114,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
4 TOWER ADOLESCENT ROOM SEMI,3040004,CDM,124,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
4 TOWER ROOM,3040010,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
ARCHER ADOLOSCENT ROOM,3041000,CDM,114,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
ARCHER ADOLOSCENT SEMI ROOM,3041002,CDM,124,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
6T MEDICAL SURGICAL ROOM,3041013,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
6T MEDICAL SURGICAL ROOM - SEMI PRIVATE,3041023,CDM,120,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
5T ORTHO NEURO TRAUMA ROOM,3050002,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
6T PEDIATRIC ROOM,3060002,CDM,113,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
6T PEDI / PEDI ICU ROOM,3060003,CDM,203,RC,,,Inpatient,,,4500,2700,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1550,100,,,per diem,pays based on per day rate,3375,100,,,per diem,pays based on per day rate,2250,50,,,percent of total billed charges,50% of total charges,3600,80,,,percent of total billed charges,80% of total charges,2700,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,3825,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,2025,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,3281,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,3150,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4500,100,,,percent of total billed charges,100% of total charges,3825,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1211.29,4500,
6T PEDIATRIC ROOM - SEMI PRIVATE,3060022,CDM,123,RC,,,Inpatient,,,900,540,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,675,100,,,per diem,pays based on per day rate,450,50,,,percent of total billed charges,50% of total charges,720,80,,,percent of total billed charges,80% of total charges,540,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,45,,,percent of total billed charges,45% of total charges,720,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,630,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,900,100,,,percent of total billed charges,100% of total charges,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,4273,
7 TOWER ROOM,3070002,CDM,110,RC,,,Inpatient,,,900,540,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,675,100,,,per diem,pays based on per day rate,450,50,,,percent of total billed charges,50% of total charges,720,80,,,percent of total billed charges,80% of total charges,540,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,45,,,percent of total billed charges,45% of total charges,720,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,630,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,900,100,,,percent of total billed charges,100% of total charges,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,4273,
7T MEDICAL ACUTE ROOM,3070004,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
8T CARDIOVASCULAR ROOM,3080002,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
10 TOWER ADULT SEMI,3100004,CDM,124,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
10 TOWER ADULT PRIVATE,3100009,CDM,114,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
ARCHER ADULT ROOM,3100100,CDM,114,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
ARCHER ADULT SEMI ROOM,3100101,CDM,124,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
10 TOWER SEMI PRIVATE EC,3120004,CDM,120,RC,,,Inpatient,,,573,343.8,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,429.75,100,,,per diem,pays based on per day rate,286.5,50,,,percent of total billed charges,50% of total charges,458.4,80,,,percent of total billed charges,80% of total charges,343.8,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,487.05,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,257.85,45,,,percent of total billed charges,45% of total charges,458.4,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,401.1,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,573,100,,,percent of total billed charges,100% of total charges,487.05,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,257.85,4273,
10 TOWER GERI SEMI,3120004,CDM,114,RC,,,Inpatient,,,1800,1080,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1350,100,,,per diem,pays based on per day rate,1350,100,,,per diem,pays based on per day rate,900,50,,,percent of total billed charges,50% of total charges,1440,80,,,percent of total billed charges,80% of total charges,1080,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1530,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,810,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1260,100,,,per diem,pays based on per day rate,1260,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1800,100,,,percent of total billed charges,100% of total charges,1530,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1800,
10T GEROPSYCH ROOM,3120009,CDM,114,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
LCMH LEAVE OF ABSENCE,3203204,CDM,180,RC,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1050,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,,,,,,,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1050,4273,
DETOX SEMI,3210004,CDM,124,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
DETOX PRIVATE,3210009,CDM,114,RC,,,Inpatient,,,1900,1140,,,,,,Other,Not Separately reimbursable,737.63,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1425,100,,,per diem,pays based on per day rate,1425,100,,,per diem,pays based on per day rate,950,50,,,percent of total billed charges,50% of total charges,1520,80,,,percent of total billed charges,80% of total charges,1140,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,855,45,,,percent of total billed charges,45% of total charges,577,100,,,per diem,pays based on per day rate,910,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,1330,100,,,per diem,pays based on per day rate,1330,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1900,100,,,percent of total billed charges,100% of total charges,1615,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,737.63,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,577,1900,
6T MEDICAL SURGICAL ROOM,3260005,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
WOMENS SPECIALTY ROOM,3400002,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
NURSERY BASSINETTE,3500002,CDM,171,RC,,,Inpatient,,,575,345,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,250,100,,,per diem,pays based on per day rate,431.25,100,,,per diem,pays based on per day rate,287.5,50,,,percent of total billed charges,50% of total charges,460,80,,,percent of total billed charges,80% of total charges,345,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,488.75,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,258.75,45,,,percent of total billed charges,45% of total charges,923,100,,,per diem,pays based on per day rate,495,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,218.5,100,,,per diem,pays based on per day rate,402.5,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,575,100,,,percent of total billed charges,100% of total charges,488.75,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,218.5,923,
NURSERY ICU ROOM,3500004,CDM,174,RC,,,Inpatient,,,12000,7200,,,,,,Other,Not Separately reimbursable,1554.55,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1650,100,,,per diem,pays based on per day rate,9000,100,,,per diem,pays based on per day rate,6000,50,,,percent of total billed charges,50% of total charges,9600,80,,,percent of total billed charges,80% of total charges,7200,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,10200,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,5400,45,,,percent of total billed charges,45% of total charges,2307,100,,,per diem,pays based on per day rate,3281,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,4560,100,,,per diem,pays based on per day rate,8400,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,12000,100,,,percent of total billed charges,100% of total charges,10200,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1554.55,12000,
NURSERY INTERMEDIATE ICU ROOM,3500006,CDM,173,RC,,,Inpatient,,,9500,5700,,,,,,Other,Not Separately reimbursable,1554.55,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1650,100,,,per diem,pays based on per day rate,7125,100,,,per diem,pays based on per day rate,4750,50,,,percent of total billed charges,50% of total charges,7600,80,,,percent of total billed charges,80% of total charges,5700,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,8075,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4275,45,,,percent of total billed charges,45% of total charges,2307,100,,,per diem,pays based on per day rate,3281,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,3610,100,,,per diem,pays based on per day rate,6650,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,9500,100,,,percent of total billed charges,100% of total charges,8075,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,1554.55,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1554.55,9500,
LABOR DELIVRY RECOVRY RM,3700002,CDM,110,RC,,,Inpatient,,,1450,870,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1087.5,100,,,per diem,pays based on per day rate,725,50,,,percent of total billed charges,50% of total charges,1160,80,,,percent of total billed charges,80% of total charges,870,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,45,,,percent of total billed charges,45% of total charges,1160,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1015,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1450,100,,,percent of total billed charges,100% of total charges,1232.5,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,652.5,4273,
VIRTUAL ER ROOM,3788033,CDM,110,RC,,,Inpatient,,,900,540,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,675,100,,,per diem,pays based on per day rate,450,50,,,percent of total billed charges,50% of total charges,720,80,,,percent of total billed charges,80% of total charges,540,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,45,,,percent of total billed charges,45% of total charges,720,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,630,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,900,100,,,percent of total billed charges,100% of total charges,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,4273,
VIRTUAL ER ICU ROOM,3788037,CDM,200,RC,,,Inpatient,,,1700,1020,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1550,100,,,per diem,pays based on per day rate,1275,100,,,per diem,pays based on per day rate,850,50,,,percent of total billed charges,50% of total charges,1360,80,,,percent of total billed charges,80% of total charges,1020,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1445,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,3281,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,1190,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1700,100,,,percent of total billed charges,100% of total charges,1445,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,4273,
9T MEDICAL ROOM,9030001,CDM,110,RC,,,Inpatient,,,900,540,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,675,100,,,per diem,pays based on per day rate,450,50,,,percent of total billed charges,50% of total charges,720,80,,,percent of total billed charges,80% of total charges,540,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,45,,,percent of total billed charges,45% of total charges,720,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,630,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,900,100,,,percent of total billed charges,100% of total charges,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,4273,
9T MEDICAL ICU ROOM,9030002,CDM,200,RC,,,Inpatient,,,4500,2700,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1550,100,,,per diem,pays based on per day rate,3375,100,,,per diem,pays based on per day rate,2250,50,,,percent of total billed charges,50% of total charges,3600,80,,,percent of total billed charges,80% of total charges,2700,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,3825,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,2025,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,3281,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,3150,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4500,100,,,percent of total billed charges,100% of total charges,3825,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1211.29,4500,
9T MEDICAL ICU TRANSITIONAL ROOM,9030004,CDM,206,RC,,,Inpatient,,,1300,780,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,975,100,,,per diem,pays based on per day rate,650,50,,,percent of total billed charges,50% of total charges,1040,80,,,percent of total billed charges,80% of total charges,780,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,1105,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,585,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,910,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1300,100,,,percent of total billed charges,100% of total charges,1105,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,585,4273,
ICU ROOM & BOARD- TRAUMA,9030008,CDM,208,RC,,,Inpatient,,,5500,3300,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1550,100,,,per diem,pays based on per day rate,4125,100,,,per diem,pays based on per day rate,2750,50,,,percent of total billed charges,50% of total charges,4400,80,,,percent of total billed charges,80% of total charges,3300,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,4675,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,2475,45,,,percent of total billed charges,45% of total charges,2272,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,3850,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,5500,100,,,percent of total billed charges,100% of total charges,4675,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,1211.29,5500,
9T MEDICAL ROOM - SEMI PRIVATE,9030021,CDM,120,RC,,,Inpatient,,,900,540,,,,,,Other,Not Separately reimbursable,1211.29,100,,,Per Diem ,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,675,100,,,per diem,pays based on per day rate,450,50,,,percent of total billed charges,50% of total charges,720,80,,,percent of total billed charges,80% of total charges,540,60,,,percent of total billed charges,60% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,45,,,percent of total billed charges,45% of total charges,720,80,,,percent of total billed charges,80% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,4273,100,,,per diem,pays based on per day rate,630,70,,,percent of total billed charges,70% of total charges,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,900,100,,,percent of total billed charges,100% of total charges,765,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,,,,,Other,NOT SEPARATELY REIMBURSABLE,405,4273,
Inpatient,1,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,346524.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,348534.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,348534.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,184690.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,187122.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,187122.65,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,387046.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,219498.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,187122.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,180947.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,387046.33,
Inpatient,2,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,179416.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,157480.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,157480.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,84009.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,85097.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,85097.45,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176061.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,99177.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,85097.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82307.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,179416.65,
Inpatient,3,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,228979.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,274215.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,274215.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,145526.07,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,147435.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,147435.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,304974.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,172694.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,147435.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142577.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,304974.56,
Inpatient,4,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,142891.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,189067.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,189067.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,100654.99,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,101965.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,101965.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,210943.45,215,MS-DRG,,Case rate,215% Medicare MS-DRG,119070,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,101965.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98615.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,210943.45,
Inpatient,5,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,122666.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,133118.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,133118.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,71171.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,72088.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,72088.22,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,149158.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,83835,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,72088.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69729.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,149158.48,
Inpatient,6,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56286.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,62210.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,62210.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,33804.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34222.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,34222.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,70853.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,39178.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,34222.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33120.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,70853.41,
Inpatient,7,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,138786.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,157767,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,157767,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,84160.53,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,85250.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,85250.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176377.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,99357.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,85250.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,176377.95,
Inpatient,8,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65118.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,67674.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,67674.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,36684.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,37140.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,37140.22,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,76887.02,215,MS-DRG,,Case rate,215% Medicare MS-DRG,42619.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,37140.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35941.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,76887.02,
Inpatient,10,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43385.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,61911.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,61911.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,33646.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34062.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,34062.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,70522.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,38990.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,34062.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32965.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,70522.5,
Inpatient,11,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60181.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,66318.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,66318.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,35969.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,36416.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,36416.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,75390.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,41766.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,36416.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35241.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,75390.05,
Inpatient,12,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45936.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,51509.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,51509.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28165.73,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28508.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,28508.15,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59036.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,32439.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,28508.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27595.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,59036.17,
Inpatient,13,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32644.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34542.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34542.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19224.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19447.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19447.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40298.98,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21754.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19447.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18835.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,40298.98,
Inpatient,14,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,127963.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,147406.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,147406.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,78701,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,79718.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,79718.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,164937.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,92833.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,79718.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77106.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,164937.05,
Inpatient,16,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,80734.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,79446.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,79446.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42887.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43426.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,43426.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,89887.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,50033.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43426.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,89887.48,
Inpatient,17,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58195.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,79446.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,79446.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42887.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43426.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,43426.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,89887.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,50033.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43426.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42019.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,89887.48,
Inpatient,18,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,448839.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,473860.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,473860.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,250733.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,254048.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,254048.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,525446.15,215,MS-DRG,,Case rate,215% Medicare MS-DRG,298425.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,254048.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,245652.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,525446.15,
Inpatient,19,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,80056.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,102810.16,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,102810.16,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,55199.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,55903.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,55903.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,115688.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,64747.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,55903.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54081.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,115688.04,
Inpatient,20,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,123888.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,108712.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,108712.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,58310,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,59054.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,59054.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,122205.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,68464.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,59054.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57128.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,123888.95,
Inpatient,21,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,90408.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,78988.97,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,78988.97,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42646.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43182.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,43182.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,89381.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,49745.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43182.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41782.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,90408.85,
Inpatient,22,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58040.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44716.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44716.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27608.6,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27943.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27943.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57868.65,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28161.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27943.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27049.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,58040.96,
Inpatient,23,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67977.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,72910.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,72910.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,39443.31,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,39936.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,39936.31,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82669.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,45917.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,39936.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38644.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,82669.26,
Inpatient,24,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47208.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,48730.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,48730.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26701.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27023.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27023.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55966.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,30689.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27023.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26160.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,55966.82,
Inpatient,25,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53901.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,56797.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,56797.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,30952.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31331.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,31331.72,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64875.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,35769.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,31331.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30325.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,64875.22,
Inpatient,26,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36698.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37981.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37981.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21036.83,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21284.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21284.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44096.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23920.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21284.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20611.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44096.96,
Inpatient,27,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30133.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31291.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31291.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17511.04,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17711.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,17711.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36708.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19706.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17711.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17156.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,36708.38,
Inpatient,28,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69789.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,77506.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,77506.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,41865.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42390.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,42390.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,87744.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,48811.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,42390.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41017.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,87744.18,
Inpatient,29,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39512.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44092.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44092.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24256.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24547.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24547.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50845.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27768.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24547.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23766.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,50845.04,
Inpatient,30,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28246.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29826.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29826.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16739.04,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16928.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16928.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35090.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18783.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16928.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16400.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,35090.57,
Inpatient,31,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52394.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,52946.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,52946.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28922.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29275.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,29275.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60622.68,215,MS-DRG,,Case rate,215% Medicare MS-DRG,33344.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,29275.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,60622.68,
Inpatient,32,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26564.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27701.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27701.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15619.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15794.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15794.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32744.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17445.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15794.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15303.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32744.18,
Inpatient,33,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20640.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20873.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20873.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12021.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12147.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12147.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25203.55,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13145.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12147.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11778.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25203.55,
Inpatient,34,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47677.53,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,50178.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,50178.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27464.24,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27797.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27797.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57566.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,31601.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27797.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26908.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,57566.12,
Inpatient,35,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28041.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29575.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29575.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16606.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16794.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16794.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34813.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18625.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16794.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16270.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,34813.6,
Inpatient,36,MS-DRG,,,,,Inpatient,,,,,,20129,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22199.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23256.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23256.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13276.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13420.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13420.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27835.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14646.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13420.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13008.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,27835.46,
Inpatient,37,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39282.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43416.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,43416.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23900.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24185.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24185.93,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50097.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27342.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24185.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23416.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,50097.93,
Inpatient,38,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19880.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20577.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20577.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11865.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11989.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11989.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24876.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12959.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11989.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11625.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24876.87,
Inpatient,39,MS-DRG,,,,,Inpatient,,,,,,12702,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13652.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14675.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14675.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8754.79,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8838.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8838.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18358.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9242.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8838.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8578.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,18358.91,
Inpatient,40,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46319.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,49524.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,49524.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27119.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27447.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27447.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56843.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,31189.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27447.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26570.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,56843.14,
Inpatient,41,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28161.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28690.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28690.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16140.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16322.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16322.41,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33836.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18068.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16322.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15814.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33836.41,
Inpatient,42,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22785.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22376.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22376.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12813.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12950.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12950.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26863.94,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14092.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12950.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12554.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26863.94,
Inpatient,52,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22214.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25009.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25009.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14200.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14356.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14356.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29771.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15750.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14356.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13913.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,29771.39,
Inpatient,53,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13619.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12653.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12653.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7689.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7758.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7758.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16126.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7968.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7758.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16126.12,
Inpatient,54,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16399.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18951.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18951.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11008.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11121.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11121.73,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23081.55,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11935.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11121.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10785.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23081.55,
Inpatient,55,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12519.53,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13803.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13803.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8295.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8372.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8372.36,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17395.92,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8692.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8372.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8127.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17395.92,
Inpatient,56,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26310.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30790.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30790.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17247.37,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17444,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,17444,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36155.83,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19391.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17444,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16898.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,36155.83,
Inpatient,57,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15190.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17533.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17533.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10260.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10364.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10364.15,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11041.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10364.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10053.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,21514.89,
Inpatient,58,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20827.53,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22223.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22223.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12732.68,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12869.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12869.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26694.92,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13995.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12869.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26694.92,
Inpatient,59,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13510.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15269.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15269.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9067.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9155.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9155.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19015.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9616.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9155.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8884.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19015.1,
Inpatient,60,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10998.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11542.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11542.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7103.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7164.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7164.91,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14898.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7268.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7164.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6960.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14898.95,
Inpatient,61,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34651.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36048.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36048.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20018.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20251.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,20251.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41962.2,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22702.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20251.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19613.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,41962.2,
Inpatient,62,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23829.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24073.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24073.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13707.33,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13856.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13856.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28737.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15160.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13856.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13430.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28737.38,
Inpatient,63,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20490.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19122.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19122.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11098.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11213.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11213.07,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23270.44,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12043.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11213.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10874.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23270.44,
Inpatient,64,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22998.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25762.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25762.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14597.25,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14758.5,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30602.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16224.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14302.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,30602.28,
Inpatient,65,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12224.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13072.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13072.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7910.27,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7982.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7982.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16589.16,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8232.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7982.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7750.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16589.16,
Inpatient,66,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8528.53,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8842.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8842.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5681.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5723.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5723.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11917.65,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5568.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5723.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5566.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11917.65,
Inpatient,67,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17088.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18223.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18223.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10624.79,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10732.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10732.99,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22277.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11476.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10732.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10410.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22277.66,
Inpatient,68,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11202.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11202.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6924.79,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6983.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6983.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14524,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7055.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6983.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6785.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14524,
Inpatient,69,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9433.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10272.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10272.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6434.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6487,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6487,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6469.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6487,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13497.06,
Inpatient,70,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20130.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23016.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23016.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13150.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13292.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13292.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27569.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14494.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13292.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12884.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27569.85,
Inpatient,71,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12126.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13656.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13656.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8217.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8294.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8294.05,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17233.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8600.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8294.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8052.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17233.99,
Inpatient,72,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9248.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10070.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10070.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6328.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6379.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6379.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13274.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6342.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6379.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6200.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13274.09,
Inpatient,73,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17413.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19459.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19459.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11276.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11393.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11393.02,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23642.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12255.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11393.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11048.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23642.57,
Inpatient,74,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12212.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13198.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13198.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7976.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8049.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16728.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8312.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16728.36,
Inpatient,75,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19499.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24614.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24614.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13992.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14145.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14145.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29335.37,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15501.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14145.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13709.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,29335.37,
Inpatient,76,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11804.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11864.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11864.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7273.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7337.3,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15255.45,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7472.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7337.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7127.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15255.45,
Inpatient,77,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18371.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19432.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19432.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11261.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11378.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23612.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12238.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11378.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11034.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23612.76,
Inpatient,78,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11384.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13079.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13079.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7913.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7985.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7985.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16596.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8236.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7985.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7753.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16596.28,
Inpatient,79,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8734.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9527.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9527.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6042.31,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6089.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6089.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12674.68,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6000.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6089.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5920.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12674.68,
Inpatient,80,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25113.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28407.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28407.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15991.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16171.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,16171.31,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33523.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17890.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16171.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15668.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,33523.93,
Inpatient,81,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9266.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11697.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11697.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7185.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7248,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7248,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15070.8,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7366.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7248,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7040.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15070.8,
Inpatient,82,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27132.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29302.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29302.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16463.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16649.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,16649.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34512.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18454.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16649.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16130.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,34512.5,
Inpatient,83,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16107.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17445.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17445.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10214.73,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10317.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10317.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21418.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10986.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10317.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10008.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,21418.34,
Inpatient,84,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10853.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11828.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11828.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7254.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7318.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7318.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15215.67,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7449.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7318.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7108.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15215.67,
Inpatient,85,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27705.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29232.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29232.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16425.91,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16611.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,16611.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34434.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18409.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16611.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16093.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,34434.39,
Inpatient,86,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15274.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16940.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16940.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9948.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10047.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10047.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20860.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10668.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10047.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9747.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20860.12,
Inpatient,87,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10350.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11398.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11398.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7027.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7087.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7087.99,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14739.88,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7178.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7087.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6886.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14739.88,
Inpatient,88,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17440.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19727.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19727.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11417.1,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11535.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11535.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23938,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12423.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11535.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11186.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23938,
Inpatient,89,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12746.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14789.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14789.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8815.1,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8899.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8899.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18485.31,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9314.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8899.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8637.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,18485.31,
Inpatient,90,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10242.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12023.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12023.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7357.2,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7421.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7421.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15430.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7571.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7421.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7208.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15430.14,
Inpatient,91,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19784.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23012.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23012.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13148.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13290.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13290.07,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27565.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14492.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13290.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12882.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27565.61,
Inpatient,92,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11851.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13197.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13197.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7976.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8048.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8048.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16726.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8311.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8048.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7815.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16726.91,
Inpatient,93,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9374.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9960.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9960.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6270.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6320.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6320.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13151.94,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6272.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6320.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6143.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13151.94,
Inpatient,94,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43600.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46594.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,46594.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25575.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25883.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,25883.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53607.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29343.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25883.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25057.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,53607.62,
Inpatient,95,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30049.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30664.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30664.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17180.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17376.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,17376.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36016.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19312.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17376.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16833.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,36016.62,
Inpatient,96,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27957.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28034.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28034.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15794.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15972.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15972.13,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33112.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17655.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15972.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15475.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,33112.04,
Inpatient,97,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45068.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46776.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,46776.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25671.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25980.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,25980.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53809.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29458.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25980.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25151.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,53809.3,
Inpatient,98,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25318.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27710.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27710.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15624.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15799.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15799.05,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32754.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17451.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15799.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15308.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,32754.11,
Inpatient,99,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16801.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16980.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16980.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9969.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10068.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10068.83,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20904.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10693.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10068.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9768,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20904.18,
Inpatient,100,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22488.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25498.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25498.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14458.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14617.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14617.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30311.08,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16058.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14617.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14165.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,30311.08,
Inpatient,101,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10647.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11699.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11699.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7186.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7248.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7248.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15072.21,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7367.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7248.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7041.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15072.21,
Inpatient,102,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13819.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15518.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15518.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9199.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9288.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9288.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19290.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9773.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9288.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9013.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19290.66,
Inpatient,103,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9941.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10834.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10834.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6730.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6787.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6787.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14117.75,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6823.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6787.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6595.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14117.75,
Inpatient,113,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26299.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32248.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32248.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18015.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18222.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18222.19,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37765.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20309.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18222.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,37765.1,
Inpatient,114,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17349.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15843.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15843.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9370.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9461.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9461.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19648.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9977.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9461.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9180.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19648.61,
Inpatient,115,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17457.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20120.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20120.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11624.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11746.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11746.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24372.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12671.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11746.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11389.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24372.66,
Inpatient,116,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22564.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23547.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23547.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13430.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13575.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13575.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28156.47,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14829.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13575.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13158.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28156.47,
Inpatient,117,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12478.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15413.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15413.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9143.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9232.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9232.27,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19174.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9707.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9232.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8959.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19174.19,
Inpatient,121,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14269.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16478.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16478.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9705.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9800.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9800.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20350.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10377.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9800.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9509.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20350.22,
Inpatient,122,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7736.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9575.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9575.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6067.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6114.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6114.74,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12727.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6030.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6114.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5945.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12727.23,
Inpatient,123,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9190.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10340.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10340.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6470.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6523.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6523.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13572.35,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6512.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6523.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6340.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13572.35,
Inpatient,124,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16802.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17001.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17001.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9980.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10080.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10080.5,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20928.31,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10707.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10080.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20928.31,
Inpatient,125,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10031.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10257.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10257.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6426.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6478.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6478.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13480.03,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6459.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6478.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6297.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13480.03,
Inpatient,135,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25689.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34110.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34110.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18996.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19216.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19216.72,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39821.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21482.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19216.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18612.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,39821.74,
Inpatient,136,MS-DRG,,,,,Inpatient,,,,,,10454,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15047.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12078.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12078.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8099.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8173.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8173.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16985.44,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7606.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8173.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7935.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,16985.44,
Inpatient,137,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18093.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19353.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19353.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11219.88,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11336.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11336.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23524.72,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12188.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11336.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10993.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23524.72,
Inpatient,138,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10265.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11134.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11134.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6888.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6947.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,6947.17,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14448.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7012.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6947.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6749.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,14448.69,
Inpatient,139,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14790.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15275.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15275.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9071.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9158.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9158.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19022.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9620.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9158.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8888.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19022.22,
Inpatient,140,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47675.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,48592.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,48592.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26628.52,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26950.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26950.41,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55814.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,30602.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26950.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26089.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,55814.81,
Inpatient,141,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26440.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26645.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26645.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15062.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15230.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15230.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31578.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16780.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15230.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14758.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31578.06,
Inpatient,142,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19237.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19871.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19871.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11493.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11612.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11612.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24097.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12514.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11612.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24097.1,
Inpatient,143,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35712.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42772.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,42772.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23561.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,23842.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49387.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26937.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23842.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23084.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,49387.76,
Inpatient,144,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21111.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22257.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22257.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12750.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12886.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12886.87,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26731.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14017.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12886.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26731.81,
Inpatient,145,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14676.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15705.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15705.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9297.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9388.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9388.16,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19496.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9890.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9388.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9109.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19496.57,
Inpatient,146,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24462.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27151.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27151.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15329.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15500.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15500.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32136.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17099.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15500.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15019.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,32136.26,
Inpatient,147,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15593.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15894.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15894.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9397.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9489.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9489.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19705.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10009.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9489.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9207.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19705.4,
Inpatient,148,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9432.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11443.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11443.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7051.52,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7112.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7112.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14789.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7206.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7112.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6909.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14789.57,
Inpatient,149,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8832.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9578.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9578.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6068.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6116.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6116.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12730.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6032.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6116.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12730.1,
Inpatient,150,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15910.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16906.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16906.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9930.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10029.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10029.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20823.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10647.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10029.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9730.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20823.18,
Inpatient,151,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8849.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9912.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9912.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6244.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6294.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6294.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13099.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6242.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6294.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6119.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13099.36,
Inpatient,152,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12949.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15282.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15282.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9074.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9162.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9162.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19029.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9624.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9162.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8891.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19029.3,
Inpatient,153,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8547.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9450.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9450.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6001.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6048.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6048.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12589.44,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5951.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6048.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5880.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12589.44,
Inpatient,154,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18538.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19783.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19783.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11446.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11566.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11566.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24000.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12459.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11566.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11215.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24000.53,
Inpatient,155,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10900.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12174.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12174.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7437.18,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7502.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7502.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15597.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7667.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7502.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7287.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15597.74,
Inpatient,156,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7890.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8430.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8430.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5464.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5503.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5503.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11463.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5309.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5503.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5354.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11463.12,
Inpatient,157,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18890.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21954.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21954.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12591.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12725.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12725.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26398.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13826.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12725.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26398.05,
Inpatient,158,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10788.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12070.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12070.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7382.28,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7447.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7447.19,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15482.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7601.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7447.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7233.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15482.71,
Inpatient,159,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7947.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8684.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8684.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5597.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5638.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5638.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11742.94,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5469.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5638.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5484.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11742.94,
Inpatient,163,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60006.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,60625,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,60625,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,32969.15,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33375.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,33375.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69102.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,38180.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,33375.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32301.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,69102.14,
Inpatient,164,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31827.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32802.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32802.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18307.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18518.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18518.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38377.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20658.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18518.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17937.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,38377.26,
Inpatient,165,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22970.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24133.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24133.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13739.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13888.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13888.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28804.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15198.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13888.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13461.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28804.14,
Inpatient,166,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44626.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,52190.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,52190.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28524.28,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28871.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,28871.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59787.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,32868.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,28871.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27946.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,59787.53,
Inpatient,167,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21797.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23405.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23405.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13355.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13500.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13500.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28000.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14740.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13500.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13085.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28000.22,
Inpatient,168,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16232.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17436.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17436.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10209.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10312.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10312.65,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21408.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10981.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10312.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10003.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21408.39,
Inpatient,173,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,39549.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,39549.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21863.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22121.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22121.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45828.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24907.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22121.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21420.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,45828.38,
Inpatient,175,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18528.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18044.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18044.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10530.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10637.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10637.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22080.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11364.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10637.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10317.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22080.23,
Inpatient,176,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10640.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10490.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10490.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6549.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6603.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6603.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13737.13,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6606.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6603.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6417.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13737.13,
Inpatient,177,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22161.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21818.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21818.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12519.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12652.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12652.67,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26247.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13740.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12652.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12266.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26247.5,
Inpatient,178,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14475.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12690.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12690.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7708.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7778.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7778.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16167.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7992.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7778.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7553.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16167.3,
Inpatient,179,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10459.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9817.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9817.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6194.82,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6243.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6243.87,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12994.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6182.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6243.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6069.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12994.28,
Inpatient,180,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20852.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22356.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22356.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12802.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12939.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26841.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14079.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12543.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26841.22,
Inpatient,181,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14162.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14162.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8484.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8563.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8563.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17792.21,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8918.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8563.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8313.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17792.21,
Inpatient,182,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9492.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9762.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9762.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6435.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6487.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6487.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13498.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6147.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6487.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13498.49,
Inpatient,183,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18683.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20250.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20250.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11692.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11815.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11815.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24516.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12753.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11815.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11456.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24516.11,
Inpatient,184,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12475.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13529.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13529.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8150.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8226.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8226.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17093.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8520.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8226.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7986.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17093.4,
Inpatient,185,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9287.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9719.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9719.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6143.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6191.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6191.67,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12886.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6121.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6191.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12886.33,
Inpatient,186,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18502.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19962.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19962.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11541.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11661.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11661.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24197.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12572.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11661.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11307.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24197.95,
Inpatient,187,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12379.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12814.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12814.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7774.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7844.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7844.17,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16303.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8070.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7844.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7617.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16303.66,
Inpatient,188,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8743.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9601.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9601.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6080.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6128.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6128.47,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12755.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6046.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6128.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5958.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12755.64,
Inpatient,189,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14694.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15845.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15845.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9371.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9463.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9463.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19651.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9979.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9463.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9182.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19651.41,
Inpatient,190,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13484.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14173.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14173.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8490.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8570.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8570.16,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17804.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8926.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8570.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8319.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17804.97,
Inpatient,191,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10598.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10919.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10919.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6775.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6832.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6832.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14211.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6876.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6832.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6639.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14211.5,
Inpatient,192,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8336.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8254.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8254.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5371.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5409.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5409.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11268.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5198.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5409.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5263.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11268.57,
Inpatient,193,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15724.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17062.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17062.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10012.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10112.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10112.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20995.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10745.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10112.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9810.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20995.06,
Inpatient,194,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10353.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10574.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10574.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6594.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6648.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6648.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13830.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6659.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6648.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6461.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13830.84,
Inpatient,195,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7979.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8046.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8046.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5261.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5298.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5298.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11038.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5067.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5298.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5155.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11038.46,
Inpatient,196,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20837.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24378.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24378.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13867.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14019.47,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29073.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15352.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14019.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13587.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,29073.99,
Inpatient,197,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12068.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12829.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12829.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7782.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7852.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7852.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16320.7,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8079.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7852.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7625.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16320.7,
Inpatient,198,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8909.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10008.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10008.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6295.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6346.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6346.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13205.9,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6303.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6346.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6168.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13205.9,
Inpatient,199,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21453.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22817.98,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22817.98,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13045.82,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13186.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13186.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27351.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14370.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13186.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12782.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27351.12,
Inpatient,200,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12901.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13852.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13852.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8321.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8398.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8398.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17449.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8723.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8398.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8153.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17449.91,
Inpatient,201,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8504.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9081.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9081.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5807.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5851,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5851,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12181.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5719.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5851,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5690.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12181.82,
Inpatient,202,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11589.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12315.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12315.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7511.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7577.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7577.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15752.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7755.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7577.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7359.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15752.56,
Inpatient,203,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8473.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8937.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8937.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5731.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5774.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5774.07,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12022.75,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5628.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5774.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5615.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12022.75,
Inpatient,204,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9511.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10583.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10583.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6598.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6653.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6653.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13840.78,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6665.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6653.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6465.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13840.78,
Inpatient,205,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20192.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23283.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23283.57,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13291.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13434.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13434.97,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27865.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14663.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13434.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13022.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27865.25,
Inpatient,206,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10618.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11749.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11749.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7212.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7275.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7275.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15127.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7399.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7275.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7067.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15127.63,
Inpatient,207,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68747.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,88848.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,88848.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,47842.37,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,48447.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,48447.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,100270.21,215,MS-DRG,,Case rate,215% Medicare MS-DRG,55954.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,48447.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46873.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,100270.21,
Inpatient,208,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30499.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34775.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34775.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19347.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19571.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,19571.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40556.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21900.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19571.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18955.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,40556.06,
Inpatient,212,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,138529.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,138529.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,74022.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,74977.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74977.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,155133.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,87242.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,74977.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72523.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,155133.85,
Inpatient,215,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,126542.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,131379.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,131379.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,70255.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,71159.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,71159.61,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,147238.15,215,MS-DRG,,Case rate,215% Medicare MS-DRG,82739.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,71159.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68832,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,147238.15,
Inpatient,216,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,120321.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,124826.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,124826.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,66801.9,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,67660.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,67660.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,140001.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,78612.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,67660.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65448.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,140001.49,
Inpatient,217,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77704.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,81868.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,81868.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,44164.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,44720.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44720.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,92562,215,MS-DRG,,Case rate,215% Medicare MS-DRG,51558.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,44720.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43269.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,92562,
Inpatient,218,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73219.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,73269.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,73269.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,39632.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40127.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40127.94,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,83065.54,215,MS-DRG,,Case rate,215% Medicare MS-DRG,46143.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,40127.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38829.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,83065.54,
Inpatient,219,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,96570.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,99179.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,99179.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,53286.28,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,53964.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,53964.13,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,111678.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,62460.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,53964.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52207,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,111678.38,
Inpatient,220,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64782.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,67454.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,67454.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,36568.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,37022.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37022.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,76644.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,42481.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,37022.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35827.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,76644.17,
Inpatient,221,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54890.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,59788.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,59788.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,32528.61,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32929.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32929.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68178.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,37653.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,32929.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,68178.93,
Inpatient,228,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63883.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,64806.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,64806.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,35172.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35608.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35608.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73719.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,40813.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,35608.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34460.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,73719.69,
Inpatient,229,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41242.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40895.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,40895.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22572.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22839.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22839.75,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47314.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25754.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22839.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22115.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,47314.09,
Inpatient,231,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,104460.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,104375.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,104375.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,56024.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,56738.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,56738.94,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,117416.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,65733.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,56738.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54889.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,117416.62,
Inpatient,232,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,71356.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,76509.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,76509.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,41339.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41858.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41858.07,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,86643.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,48183.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,41858.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40502.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,86643.4,
Inpatient,233,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,94948.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,100316.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,100316.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,53885.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,54571.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,54571.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,112933.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,63176.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,54571.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52794.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,112933.97,
Inpatient,234,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63951.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,66853.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,66853.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,36251.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,36702.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36702.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,75980.86,215,MS-DRG,,Case rate,215% Medicare MS-DRG,42102.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,36702.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35517.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,75980.86,
Inpatient,235,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73157.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,75634.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,75634.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,40878.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41391.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41391.02,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,85677.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,47632.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,41391.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40051.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,85677.57,
Inpatient,236,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49102.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,51976.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,51976.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28411.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28757.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28757.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59551.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,32733.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,28757.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27836.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,59551.74,
Inpatient,239,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57719.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,61823.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,61823.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,33600.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34015.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34015.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,70425.9,215,MS-DRG,,Case rate,215% Medicare MS-DRG,38935.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,34015.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32920.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,70425.9,
Inpatient,240,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33423.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36131.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36131.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20061.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20295.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20295.72,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42053.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22754.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20295.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19655.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42053.1,
Inpatient,241,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19084.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17875.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17875.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10469.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10575.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10575.72,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21952.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11257.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10575.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10258.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21952.41,
Inpatient,242,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44675.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44438.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44438.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24439.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24731.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24731.96,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51227.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27986.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24731.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23944.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,51227.11,
Inpatient,243,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30184.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29293.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29293.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16458.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16644.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16644.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34502.54,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18448.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16644.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16125.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,34502.54,
Inpatient,244,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24728.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23530.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23530.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13421.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13566.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13566.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28137.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14818.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13566.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13149.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28137.97,
Inpatient,245,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64932.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,58281.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,58281.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31734.24,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32124.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32124.31,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,66514.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,36704.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,32124.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31091.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,66514.26,
Inpatient,250,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30223.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30235.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30235.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16954.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17147.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2538,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17147.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35542.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19041.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17147.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16611.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,35542.23,
Inpatient,251,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19875.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20410.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20410.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11777.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11900.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2538,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11900.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24692.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12853.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11900.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11539,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24692.23,
Inpatient,252,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39858.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43135.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,43135.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23752.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24036.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24036.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49788.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27165.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24036.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23271.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,49788.3,
Inpatient,253,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31803.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32811.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32811.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18312.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18523.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18523.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38387.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20663.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18523.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17941.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,38387.18,
Inpatient,254,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21763.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22316.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22316.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12781.48,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12918.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12918.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26797.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14054.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12918.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12523.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26797.18,
Inpatient,255,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30385.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35336.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,35336.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19642.65,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19871.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19871.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41175.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22253.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19871.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19245.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,41175.33,
Inpatient,256,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19705.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21089.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21089.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12134.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12263.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12263.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25442.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13281.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12263.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11889.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25442.17,
Inpatient,257,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13964.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12745.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12745.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7738.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7807.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7807.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16228.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8027.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7807.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7581.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,16228.39,
Inpatient,258,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37969.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34837.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34837.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19379.68,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19604.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19604.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40624.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21939.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19604.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18987.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,40624.25,
Inpatient,259,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25039.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24007.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24007.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13672.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13821.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13821.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28664.92,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15119.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13821.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13396.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28664.92,
Inpatient,260,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42754.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42639.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,42639.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23491.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23771.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23771.08,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49240.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26853.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23771.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23015.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,49240.05,
Inpatient,261,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23896.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24203.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24203.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13775.78,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13926.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13926.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28880.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15242.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13926.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28880.82,
Inpatient,262,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20448.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21161.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21161.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12172.82,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12301.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12301.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25521.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13326.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12301.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25521.69,
Inpatient,263,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27723.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36336.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36336.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20169.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20405.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20405.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42280.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22884.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20405.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19761.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42280.36,
Inpatient,264,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38994.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42006.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,42006.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23157.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23433.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23433.17,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48541.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26454.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23433.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22688.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,48541.26,
Inpatient,265,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40335.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,45454.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,45454.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24974.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25274.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25274.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52349.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28626.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25274.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24469.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,52349.18,
Inpatient,266,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,84469.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,80335.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,80335.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,43356.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43901.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43901.39,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,90868.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,50593.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43901.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42478.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,90868.93,
Inpatient,267,MS-DRG,,,,,Inpatient,,,,,,54326,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67092.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,62767.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,62767.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,34098.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34519.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34519.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,71468.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,39529.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,34519.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33407.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,71468.46,
Inpatient,268,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,83455.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,88163.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,88163.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,47481.11,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,48081.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,48081.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,99513.15,215,MS-DRG,,Case rate,215% Medicare MS-DRG,55523.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,48081.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46519.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,99513.15,
Inpatient,269,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51716.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,53486.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,53486.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,29207.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29563.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29563.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,61219.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,33684.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,29563.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28616.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,61219.25,
Inpatient,270,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62166.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,65040.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,65040.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,35295.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35733.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35733.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73978.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,40960.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,35733.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34581.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,73978.18,
Inpatient,271,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42731.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44452.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44452.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24446.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24739.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51242.73,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27995.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24739.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23951.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,51242.73,
Inpatient,272,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32219.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31376.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31376.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17555.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17756.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17756.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36802.08,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19759.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17756.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17200.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,36802.08,
Inpatient,273,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45863,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,50122.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,50122.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27434.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27767.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27767.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57503.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,31565.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27767.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26879.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,57503.6,
Inpatient,274,MS-DRG,,,,,Inpatient,,,,,,36077,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39389.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41682.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41682.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22986.82,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23260.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23260.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48183.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26250.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23260.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22521.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,48183.33,
Inpatient,275,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,90492.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,90492.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,48708.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,49325.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49325.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,102085.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,56989.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,49325.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47722.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,102085.41,
Inpatient,276,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,79873.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,79873.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,43112.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43654.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43654.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,90359.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,50302.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43654.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42239.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,90359.01,
Inpatient,277,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,61509.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,61509.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,33435.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33848.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33848.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,70079.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,38737.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,33848.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32758.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,70079.33,
Inpatient,278,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,57368.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,57368.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31253.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31636.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31636.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65505.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,36129.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,31636.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30620.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,65505.82,
Inpatient,279,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41165.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41165.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22714.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22983.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22983.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47612.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25924.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22983.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22254.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,47612.34,
Inpatient,280,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19258.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20405.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20405.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11774.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11897.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11897.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24686.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12850.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11897.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24686.52,
Inpatient,281,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11153.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11742.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11742.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7209.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7272.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7272.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15120.55,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7395.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7272.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7064.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15120.55,
Inpatient,282,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8702.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9236,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9236,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5888.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5933.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5933.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12352.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5816.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5933.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5769.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12352.28,
Inpatient,283,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22348.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25355.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25355.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14383.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14541.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14541.47,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30153.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15968.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14541.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14092.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,30153.46,
Inpatient,284,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8669.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9513.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9513.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6034.86,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6081.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6081.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12659.07,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5991.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6081.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5913.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12659.07,
Inpatient,285,MS-DRG,,,,,Inpatient,,,,,,5440,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5928.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6285.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,6285.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4333.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4357.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4357.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9094.02,215,MS-DRG,,Case rate,215% Medicare MS-DRG,3958.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4357.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4246.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,9094.02,
Inpatient,286,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25603.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27724.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27724.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15631.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15806.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15806.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32769.72,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17460.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15806.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15315.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,32769.72,
Inpatient,287,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13364.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13911.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13911.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8352.18,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8430.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8430.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17515.21,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8760.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8430.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8183.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17515.21,
Inpatient,288,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32184.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33350.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,33350.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18596.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18810.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,18810.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38982.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21003.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18810.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18219.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,38982.32,
Inpatient,289,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19698.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19005.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19005.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11036.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11150.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11150.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23141.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11969.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11150.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10813.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23141.25,
Inpatient,290,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12307.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13185.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13185.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8375.91,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8454.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8454.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17564.94,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8304.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8454.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8206.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17564.94,
Inpatient,291,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15200.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16513.16,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16513.16,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9723.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9819.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9819.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20388.59,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10399.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9819.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9526.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20388.59,
Inpatient,292,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10349.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11016.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11016.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6826.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6884,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6884,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14318.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6937.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6884,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6688.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14318.04,
Inpatient,293,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7069.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7221.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7221.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4827.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4857.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,4857.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10128,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4548.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4857.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4729.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10128,
Inpatient,294,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15374.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14066.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14066.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8434.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8513.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8513.15,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17687.08,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8858.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8513.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8263.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17687.08,
Inpatient,295,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11794.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8122.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8122.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6423.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6476,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6476,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13474.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5115.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6476,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6294.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13474.32,
Inpatient,296,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19118.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20619.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20619.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11887.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12012.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12012.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24923.75,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12985.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12012.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11647.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24923.75,
Inpatient,297,MS-DRG,,,,,Inpatient,,,,,,8111,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8473.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9371.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9371.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5959.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6005.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6005.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12501.43,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5901.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6005.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12501.43,
Inpatient,298,MS-DRG,,,,,Inpatient,,,,,,4886,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5858.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5645.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,5645.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4001.52,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4021.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,4021.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8398.03,215,MS-DRG,,Case rate,215% Medicare MS-DRG,3555.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4021.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3921.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,8398.03,
Inpatient,299,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18368.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20272.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20272.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11704.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11827.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11827.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24540.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12767.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11827.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11467.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24540.26,
Inpatient,300,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12509.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13723.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13723.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8253.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8329.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8329.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17307.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8642.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8329.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8086.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17307.85,
Inpatient,301,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8906.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9129.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9129.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5832.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5876.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5876.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12234.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5749.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5876.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5714.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12234.4,
Inpatient,302,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13121.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14419.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14419.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8619.91,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8701.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8701.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18076.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9080.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8701.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8445.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,18076.26,
Inpatient,303,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8121.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8464.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8464.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5481.79,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5521.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5521.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11500.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5330.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5521.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5371.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11500.06,
Inpatient,304,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13147.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14778.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14778.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8809.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8892.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8892.97,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18472.54,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9306.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8892.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8631.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,18472.54,
Inpatient,305,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8867.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9691.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9691.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6128.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6176.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6176.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12855.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6103.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6176.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6004.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12855.1,
Inpatient,306,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18066.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19765.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19765.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11437.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11556.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11556.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23980.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12448.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11556.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11206.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23980.61,
Inpatient,307,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10431.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12123.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12123.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7410.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7475.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7475.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15540.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7635.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7475.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7260.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15540.91,
Inpatient,308,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14392.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15462.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15462.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9169.6,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9258.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9258.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19228.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9737.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9258.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8984.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19228.18,
Inpatient,309,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8994.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9578.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9578.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6068.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6116.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6116.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12730.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6032.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6116.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5946.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12730.1,
Inpatient,310,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6702.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7112.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7112.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4769.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,4799.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4479.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4799.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4673.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10007.28,
Inpatient,311,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8371.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8978.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8978.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5752.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5796.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5796.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12068.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5654.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5796.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5636.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12068.19,
Inpatient,312,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10051.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11106.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11106.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6873.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6932.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6932.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14417.44,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6994.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6932.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6735.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14417.44,
Inpatient,313,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8645.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9306.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9306.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5925.73,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5971.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5971.19,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12430.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5861.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5971.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5806.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12430.39,
Inpatient,314,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24985.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26926.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26926.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15210.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15380.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15380.08,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31887.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16957.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15380.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14903.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,31887.69,
Inpatient,315,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11666.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12441.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12441.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7577.48,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7645,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7645,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15891.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7835.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7645,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7424.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15891.76,
Inpatient,316,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8669.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8909.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8909.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5716.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5758.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5758.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11991.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5610.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5758.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5601.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11991.48,
Inpatient,319,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51750.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,56101.54,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,56101.54,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,30585.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30960.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,30960.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64106.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,35331.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,30960.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29966.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,64106.81,
Inpatient,320,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28831.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28630.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28630.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16108.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16290.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2307,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16290.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33769.67,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18030.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16290.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15782.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33769.67,
Inpatient,321,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36973.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36973.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20505.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20745.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20745.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42983.43,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23285.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20745.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20090.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42983.43,
Inpatient,322,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23452.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23452.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13379.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13524.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13524.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28051.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14769.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13524.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13109.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28051.34,
Inpatient,323,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,53247.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,53247.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,29081.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29436.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29436.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60955.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,33534,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,29436.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28492.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,60955.05,
Inpatient,324,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38181.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38181.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21141.9,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21390.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21390.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44317.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24045.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21390.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20714.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44317.14,
Inpatient,325,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34010.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34010.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18943.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19163.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19163.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39710.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21418.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19163.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18560.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,39710.95,
Inpatient,326,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63715.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,65324.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,65324.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,35445.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35885.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,35885.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,74292.07,215,MS-DRG,,Case rate,215% Medicare MS-DRG,41139.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,35885.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34728.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,74292.07,
Inpatient,327,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30737.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32120.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32120.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17948.2,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18154.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18154.19,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37624.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20228.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18154.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17585.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,37624.48,
Inpatient,328,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19977.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20544.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20544.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11847.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11972.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11972.02,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24839.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12938.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11972.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11608.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24839.93,
Inpatient,329,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58561.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,58093.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,58093.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31635.28,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32024.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,32024.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,66306.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,36586.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,32024.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30994.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,66306.89,
Inpatient,330,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30553.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30509.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30509.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17098.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17293.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,17293.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35844.78,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19214.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17293.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16753.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,35844.78,
Inpatient,331,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20500.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21504.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21504.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12353.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12485.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12485.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25900.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13543.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12485.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12104.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25900.95,
Inpatient,332,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49875.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46657.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,46657.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25789.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26100.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26100.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54056.43,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29383.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26100.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25267.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,54056.43,
Inpatient,333,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25663.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26745.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26745.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15115.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15283.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15283.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31688.83,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16843.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15283.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14810.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31688.83,
Inpatient,334,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19279.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20644.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20644.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11900.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12025.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12025.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24950.72,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13001.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12025.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11659.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24950.72,
Inpatient,335,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46903.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,45980.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,45980.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25251.95,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25555.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,25555.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52930.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28957.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25555.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24740.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,52930.09,
Inpatient,336,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27461.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27077.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27077.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15290.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15461.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15461.13,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32055.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17052.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15461.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14981.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32055.3,
Inpatient,337,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19623.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19246.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19246.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11163.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11279.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11279.02,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23406.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12120.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11279.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10938.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23406.82,
Inpatient,344,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33778.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35246.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,35246.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19595.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19823.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19823.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41075.88,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22197.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19823.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19198.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,41075.88,
Inpatient,345,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18921.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19814.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19814.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11463.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11582.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11582.61,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24034.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12478.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11582.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11231.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24034.64,
Inpatient,346,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15285.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16563.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16563.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9749.77,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9846.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9846.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20443.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10431.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9846.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9552.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20443.97,
Inpatient,347,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29539.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32785.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32785.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18298.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18509.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18509.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38358.8,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20647.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18509.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17928.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,38358.8,
Inpatient,348,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16156.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16738.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16738.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9841.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9939.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9939.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20637.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10541.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9939.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9643.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20637.14,
Inpatient,349,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11736.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12550.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12550.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7635.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7703.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,7703.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16012.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7903.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7703.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7481.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,16012.49,
Inpatient,350,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29420.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30868.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30868.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17288.04,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17485.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,17485.22,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36241.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19440,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17485.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16938.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,36241.06,
Inpatient,351,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17890.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18721.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18721.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10887.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10998.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10998.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22827.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11790.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10998.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10667.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22827.3,
Inpatient,352,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13236.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14263.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14263.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8537.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8618.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8618.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17904.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8982.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8618.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8365.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17904.39,
Inpatient,353,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36253.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37611.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37611.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20841.65,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21086.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21086.27,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43687.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23686.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21086.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20419.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,43687.93,
Inpatient,354,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21390.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22093.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22093.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12664.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12799.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12799.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26551.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13914.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12799.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12408.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26551.46,
Inpatient,355,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16302,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17525.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17525.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10256.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10360.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10360.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21506.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11037.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10360.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10049.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21506.4,
Inpatient,356,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51628.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,55031.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,55031.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,30021.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30388.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,30388.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,62925.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,34657.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,30388.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29413.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,62925.09,
Inpatient,357,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27187.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28254.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28254.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15910.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16089.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16089.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33354.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17794.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16089.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15589.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33354.93,
Inpatient,358,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16168.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16477.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16477.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9704.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9800.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9800.27,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20348.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10376.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9800.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9508.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20348.81,
Inpatient,368,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23359.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21247.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21247.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12218.24,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12347.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12347.73,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25616.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13381.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12347.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11971.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25616.87,
Inpatient,369,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12910.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12711.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12711.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7719.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7789.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7789.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16190.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8005.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7789.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7564.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16190.04,
Inpatient,370,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9565.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9565.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6061.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6109.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6109.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12715.88,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6023.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6109.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5939.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12715.88,
Inpatient,371,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20748.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22478.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22478.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12866.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13005.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13005.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26976.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14156.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13005.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12606.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26976.17,
Inpatient,372,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12336.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13405.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13405.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8085.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8160.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8160.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16957.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8442.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8160.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7922.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16957.01,
Inpatient,373,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8924.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9215.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9215.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5877.6,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5922.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5922.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12329.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5803.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5922.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5759.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12329.52,
Inpatient,374,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24853.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26996.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26996.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15247.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15417.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15417.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31965.83,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17001.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15417.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14939.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,31965.83,
Inpatient,375,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14473.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15412.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15412.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9143.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9231.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9231.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19172.78,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9706.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9231.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8958.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19172.78,
Inpatient,376,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10773.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11464.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11464.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7063.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7123.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7123.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14813.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7220.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7123.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6920.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14813.74,
Inpatient,377,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21587.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23026.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23026.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13155.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13297.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13297.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27581.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14501.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13297.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12889.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27581.23,
Inpatient,378,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11907.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12653.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12653.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7689.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7758.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7758.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16126.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7968.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7758.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7534.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16126.12,
Inpatient,379,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7636.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8144.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8144.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5313.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5350.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5350.3,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11146.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5128.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5350.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5206.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11146.39,
Inpatient,380,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22610.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25061.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25061.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14227.86,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14384.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14384.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29828.2,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15782.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14384.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13940.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,29828.2,
Inpatient,381,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12695.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13800.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13800.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8293.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8370.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8370.97,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17393.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8691.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8370.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8126.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17393.06,
Inpatient,382,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9211.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9737.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9737.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6152.79,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6201.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6201.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12906.2,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6132.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6201.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6028.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12906.2,
Inpatient,383,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15731.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17983.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17983.26,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10498.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10604.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10604.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22012.02,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11325.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10604.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10285.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22012.02,
Inpatient,384,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10700.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11263.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11263.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6956.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7015.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7015.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14590.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7093.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7015.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6816.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14590.74,
Inpatient,385,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19443.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20153.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20153.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11641.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11763.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11763.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24408.16,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12691.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11763.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11406.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24408.16,
Inpatient,386,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11926.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12496.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12496.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7606.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7674.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7674.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15952.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7869.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7674.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7453.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15952.85,
Inpatient,387,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8565.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8798.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8798.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5658.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5699.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5699.9,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11869.37,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5541.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5699.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5544.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11869.37,
Inpatient,388,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18152.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18694.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18694.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10872.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10984.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10984.36,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22797.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11773.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10984.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10653.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22797.48,
Inpatient,389,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9866.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10243.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10243.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6419.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6471.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6471.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13464.42,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6450.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6471.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6289.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13464.42,
Inpatient,390,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6988.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7189.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7189.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4810.11,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4840.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,4840.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10092.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4527.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4840.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4713.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10092.51,
Inpatient,391,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14971.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16407.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16407.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9667.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9763.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9763.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20272.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10333.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9763.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9472.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20272.11,
Inpatient,392,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9178.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10104.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10104.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6345.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6397.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6397.03,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13311.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6363.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6397.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6218.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13311.01,
Inpatient,393,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19909.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20830.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20830.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11998.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12125.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12125.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25156.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13118.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12125.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11756.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25156.66,
Inpatient,394,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11276.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12050.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12050.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7371.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7436.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7436.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15459.98,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7588.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7436.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7222.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15459.98,
Inpatient,395,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7808.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8327.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8327.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5409.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5448.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5448.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11349.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5244.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5448.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5300.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11349.5,
Inpatient,397,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28895.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28895.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16248.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16431.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16431.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34062.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18197.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16431.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15919.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,34062.24,
Inpatient,398,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19463.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19463.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11278.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11395.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11395.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23646.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12257.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11395.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11050.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23646.87,
Inpatient,399,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14316.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14316.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8565.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8646.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8646.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17962.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9016.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8646.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17962.64,
Inpatient,405,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68765.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,70806.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,70806.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,38334.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38812.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,38812.67,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,80345.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,44592.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,38812.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37558.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,80345.61,
Inpatient,406,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34527.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37136.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37136.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20591.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20832.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,20832.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43163.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23387.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20832.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20174.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,43163.81,
Inpatient,407,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25384.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27665.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27665.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15600.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15775,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15775,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32704.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17423.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15775,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15284.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32704.38,
Inpatient,408,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44978.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47873.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,47873.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26249.66,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26566.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26566.5,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55020.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,30149.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26566.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25718.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,55020.87,
Inpatient,409,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25365.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25174.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25174.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14287.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14444.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14444.61,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29953.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15854.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14444.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13998.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,29953.18,
Inpatient,410,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18796.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20131.16,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20131.16,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11629.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11751.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11751.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24384.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12678.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11751.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11394.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24384.01,
Inpatient,411,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44985.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37048.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37048.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21628.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21883.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21883.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45336.94,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23332.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21883.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21190.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,45336.94,
Inpatient,412,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27295.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26308.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26308.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15024.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15191.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15191.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31498.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16568.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15191.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14721.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31498.49,
Inpatient,413,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20744.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19416.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19416.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11253.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11369.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11369.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23594.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12227.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11369.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23594.3,
Inpatient,414,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43485.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,45340.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,45340.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24914.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25213.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,25213.43,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,52222.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28554.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25213.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24410.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,52222.76,
Inpatient,415,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24349.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25412.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25412.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14412.9,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14571.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14571.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30215.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16003.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14571.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14121.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30215.96,
Inpatient,416,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17046.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17224.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17224.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10098.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10199.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10199.31,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21174.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10847.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10199.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9894.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21174.01,
Inpatient,417,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29055.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29810.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29810.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16730.9,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16920.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16920.64,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35073.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18774.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16920.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16392.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,35073.53,
Inpatient,418,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20242.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21025.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21025.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12100.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12228.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12228.89,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25371.13,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13241.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12228.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11856.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25371.13,
Inpatient,419,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15763.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16890.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16890.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9921.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10020.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10020.74,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20804.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10636.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10020.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9721.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20804.74,
Inpatient,420,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42145.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41167.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41167.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22715.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22985.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,22985.36,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47615.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25926.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22985.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22256,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,47615.18,
Inpatient,421,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22861.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21988.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21988.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12608.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12743.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12743.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26434.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13847.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12743.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12353.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26434.97,
Inpatient,422,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17421.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18147.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18147.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10584.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10692.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10692.47,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22193.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11429.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10692.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10370.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22193.85,
Inpatient,423,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50168.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,50300.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,50300.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27528.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27862.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27862.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57701.07,215,MS-DRG,,Case rate,215% Medicare MS-DRG,31678.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27862.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26971.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,57701.07,
Inpatient,424,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27374.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26846.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26846.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15469.55,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15642.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15642.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32430.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16907.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15642.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32430.25,
Inpatient,425,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18489.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20603.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20603.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11878.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12003.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12003.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24905.27,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12975.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12003.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11638.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24905.27,
Inpatient,432,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22541.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24643.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24643.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14007.59,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14160.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14160.96,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29366.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15519.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14160.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13724.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,29366.6,
Inpatient,433,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12343.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13260.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13260.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8009.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8082.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8082.5,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16796.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8351.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8082.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7847.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16796.51,
Inpatient,434,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7439.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8610.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8610.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5559.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5599.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5599.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11662,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5422.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5599.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5447.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11662,
Inpatient,435,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21014.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22635.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22635.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12949.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13088.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13088.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27149.42,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14255.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13088.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12687.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27149.42,
Inpatient,436,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13441.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14156.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14156.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8481.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8561.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8561.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17786.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8915.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8561.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8310.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17786.52,
Inpatient,437,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10737.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10689.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10689.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6654.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6709.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6709.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13957.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6731.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6709.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6520.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13957.25,
Inpatient,438,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19149.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21463.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21463.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12332.11,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12463.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12463.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25855.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13517.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12463.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12082.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25855.49,
Inpatient,439,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10129.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10999.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10999.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6817.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6875.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6875.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14299.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6927.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6875.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6680.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14299.56,
Inpatient,440,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7917.67,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7917.67,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5193.73,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5229.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5229.41,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10896.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4986.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5229.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5089.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10896.41,
Inpatient,441,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22525.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23513.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23513.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13412.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13557.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13557.93,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28119.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14808.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13557.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13141.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28119.53,
Inpatient,442,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11146.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12237.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12237.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7470.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7536.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7536.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15667.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7707.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7536.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7319.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15667.34,
Inpatient,443,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7948.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9192.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9192.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5865.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5910.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5910.07,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12303.98,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5789.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5910.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5747.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12303.98,
Inpatient,444,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20034.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21005.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21005.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12090.82,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12218.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12218.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25349.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13228.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12218.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11846.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25349.85,
Inpatient,445,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12913.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13978.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13978.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8387.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8465.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8465.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17589.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8803.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8465.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8218.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17589.09,
Inpatient,446,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9786.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10308.67,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10308.67,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6453.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6506.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6506.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13536.86,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6492.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6506.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6323.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13536.86,
Inpatient,453,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,110118.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,113972.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,113972.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,61082.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,61864.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,61864.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,128015.21,215,MS-DRG,,Case rate,215% Medicare MS-DRG,71777.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,61864.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59844.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,128015.21,
Inpatient,454,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73025.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,78666.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,78666.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42476.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43009.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,43009.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,89025.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,49542.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43009.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41616.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,89025.32,
Inpatient,455,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57303.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,59235.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,59235.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,32237.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32633.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,32633.94,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67568.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,37305.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,32633.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31584.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,67568.18,
Inpatient,456,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,103071,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,108416.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,108416.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,58154.11,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,58896.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,58896.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,121879.31,215,MS-DRG,,Case rate,215% Medicare MS-DRG,68278.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,58896.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56976.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,121879.31,
Inpatient,457,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77853.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,78138.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,78138.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42198.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42728.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,42728.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88442.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,49209.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,42728.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41343.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,88442.99,
Inpatient,458,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60016.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,58276.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,58276.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31731.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32121.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,32121.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,66508.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,36701.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,32121.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31089.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,66508.62,
Inpatient,459,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,80701,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,85302.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,85302.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,45973.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46553.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46553.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,96354.29,215,MS-DRG,,Case rate,215% Medicare MS-DRG,53721.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,46553.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45042.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,96354.29,
Inpatient,460,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47109.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47046.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,47046.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25813.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26124.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26124.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54107.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29628.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26124.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25291.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,54107.57,
Inpatient,461,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72889.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,87697.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,87697.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,47235.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,47832.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47832.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,98998.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,55229.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,47832.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46279.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,98998.99,
Inpatient,462,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37649.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36608.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36608.31,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20312.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20550.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20550.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42580.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23055.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20550.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19901.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42580.05,
Inpatient,463,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64363.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,72844.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,72844.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,39408.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,39901.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,39901.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82596.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,45875.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,39901.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38610.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,82596.84,
Inpatient,464,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35666.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38603.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38603.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21364.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21615.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21615.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44783,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24311.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21615.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20931.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44783,
Inpatient,465,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22101.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24061.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24061.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13701.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13850.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13850.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28724.55,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15153.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13850.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13424.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28724.55,
Inpatient,466,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,64068.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,66708.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,66708.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,36175.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,36624.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36624.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,75820.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,42011.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,36624.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35442.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,75820.38,
Inpatient,467,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42876.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44839.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44839.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24650.78,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24946.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24946.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51670.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28239.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24946.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24151.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,51670.28,
Inpatient,468,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33586.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34335.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34335.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19115.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19336.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19336.91,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40070.31,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21623.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19336.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18728.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,40070.31,
Inpatient,469,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36984.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42826.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,42826.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23590.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23871.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23871.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49447.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26971.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23871.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23112.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,49447.39,
Inpatient,470,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22775.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24201.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24201.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13775.11,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13925.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13925.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28879.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15241.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13925.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13496.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28879.41,
Inpatient,471,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60161.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,63266.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,63266.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,34361.31,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34786.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34786.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72019.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,39843.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,34786.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33665.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,72019.51,
Inpatient,472,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36598.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38011.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38011.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21052.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21299.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21299.87,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44129.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23938.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21299.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20626.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44129.64,
Inpatient,473,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30429.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31647.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31647.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17698.78,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17901.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17901.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37101.79,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19930.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17901.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17340.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,37101.79,
Inpatient,474,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48852.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,55341.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,55341.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,30184.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30554.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,30554.22,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63267.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,34852.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,30554.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29573.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,63267.39,
Inpatient,475,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26322.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27584.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27584.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15557.68,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15731.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15731.75,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32614.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17372.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15731.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15243.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32614.93,
Inpatient,476,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13906.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15136.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15136.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8998.1,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9084.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9084.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18868.79,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9532.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9084.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8816.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,18868.79,
Inpatient,477,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40256.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43331.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,43331.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23855.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24140.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24140.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50004.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27288.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24140.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23372.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,50004.18,
Inpatient,478,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28265.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30658.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30658.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17177.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17373.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,17373.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36009.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19307.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17373.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16830.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,36009.56,
Inpatient,479,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21686.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23974.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23974.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13655.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13803.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13803.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28628,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15098.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13803.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13379.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28628,
Inpatient,480,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36264.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37927.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37927.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21008.37,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21255.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21255.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44037.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23886.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21255.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20583.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44037.32,
Inpatient,481,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25121.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26686.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26686.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15084.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15252.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15252.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31623.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16806.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15252.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14779.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31623.51,
Inpatient,482,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19724.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20429.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20429.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11787.18,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11910.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11910.9,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24713.54,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12866.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11910.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11548.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24713.54,
Inpatient,483,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28592.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31951.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31951.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17858.73,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18063.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18063.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37436.98,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20122.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18063.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17497.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,37436.98,
Inpatient,485,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40864.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42366.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,42366.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23347.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23625.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23625.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48938.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26681.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23625.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22874.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,48938.95,
Inpatient,486,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25760.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25830.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25830.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14633.18,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14794.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14794.9,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30677.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16267.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14794.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30677.57,
Inpatient,487,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19657.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19870.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19870.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11492.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11612.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11612.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24095.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12513.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11612.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11260.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24095.71,
Inpatient,488,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23678.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27094.5,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27094.5,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15299.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15470.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15470.05,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32073.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17063.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15470.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14990.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32073.76,
Inpatient,489,MS-DRG,,,,,Inpatient,,,,,,13778,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15558.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15918.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15918.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9410.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9502.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9502.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19732.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10025.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9502.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9220.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,19732.41,
Inpatient,492,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41587.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44528.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44528.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24486.75,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24780.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24780.05,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51326.55,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28043.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24780.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23991.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,51326.55,
Inpatient,493,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27874.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30889.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30889.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17299.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17496.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17496.9,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36265.21,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19453.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17496.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16949.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,36265.21,
Inpatient,494,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22192.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24041.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24041.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13690.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13839.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28701.86,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15140.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13839.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13413.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28701.86,
Inpatient,495,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43648.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46060.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,46060.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25293.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25598.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25598.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53018.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29007.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25598.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24782.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,53018.17,
Inpatient,496,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23807,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25562.67,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25562.67,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14492.21,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14652.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14652.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30382.16,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16098.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14652.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14199.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30382.16,
Inpatient,497,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17396.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18358.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18358.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10695.95,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10805.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10805.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22426.78,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11561.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10805.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10479.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22426.78,
Inpatient,498,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30965.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33581.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,33581.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18718.15,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18934.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18934.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39237.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21149.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18934.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,39237.96,
Inpatient,499,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14370.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16589.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16589.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9763.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9860.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9860.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20472.42,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10447.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9860.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9566.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20472.42,
Inpatient,500,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38226.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41707.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41707.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23000.37,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23273.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,23273.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48211.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26266.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23273.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22534.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,48211.71,
Inpatient,501,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21022.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22324.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22324.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12785.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12922.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12922.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26805.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14059.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12922.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12527.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26805.69,
Inpatient,502,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15973.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17783.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17783.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10392.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10498.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10498.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21791.88,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11199.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10498.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10183.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21791.88,
Inpatient,503,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31647.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34493.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34493.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19198.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19421.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19421.39,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40244.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21723.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19421.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18810.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,40244.99,
Inpatient,504,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21273.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22213.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22213.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12727.25,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12863.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12863.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26683.54,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13989.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12863.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12469.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26683.54,
Inpatient,505,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21273.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21938.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21938.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12582.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12716.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12716.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26379.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13816.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12716.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12327.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26379.62,
Inpatient,506,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17780.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18811.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18811.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10934.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11046.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11046.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22926.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11847.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11046.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10713.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22926.76,
Inpatient,507,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24699.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27417.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27417.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15469.55,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15642.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15642.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32430.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17266.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15642.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15156.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32430.25,
Inpatient,508,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16895.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18443.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18443.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10740.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10850.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10850.45,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22520.55,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11615.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10850.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10523.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22520.55,
Inpatient,509,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20212.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17057.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17057.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10280.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10384.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10384.08,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21556.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10742.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10384.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10072.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21556.11,
Inpatient,510,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32883.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34991.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34991.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19460.99,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19687.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19687.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40794.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22036.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19687.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19067.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,40794.66,
Inpatient,511,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23579.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25643.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25643.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14534.9,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14695.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14695.31,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30471.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16149.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14695.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14240.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30471.61,
Inpatient,512,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18630.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20756.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20756.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11959.33,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12085.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12085.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25074.29,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13071.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12085.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11717.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25074.29,
Inpatient,513,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18840.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20848.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20848.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12008.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12134.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12134.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25176.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13130.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12134.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25176.57,
Inpatient,514,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11974.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13395.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13395.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8080.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8154.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8154.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16945.68,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8436.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8154.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7917.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,16945.68,
Inpatient,515,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37640.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40662.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,40662.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22449.33,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22715.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,22715.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47056.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25608.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22715.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21995.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,47056.96,
Inpatient,516,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23524.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26248.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26248.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14853.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15018.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15018.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31139.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16530.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15018.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14553.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31139.17,
Inpatient,517,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16757.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19220.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19220.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11150.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11265.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11265.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23378.37,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12104.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11265.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10924.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23378.37,
Inpatient,518,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42989,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46968.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,46968.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25772.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26082.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26082.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54020.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29579.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26082.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25250.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,54020.93,
Inpatient,519,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23490.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25319.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25319.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14364.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14522.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14522.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30113.68,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15945.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14522.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14073.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30113.68,
Inpatient,520,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16998.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18411.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18411.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10723.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10833.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10833.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22485,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11595.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10833.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10507.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22485,
Inpatient,521,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36748.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38510.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38510.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21315.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21566.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21566.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44680.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24253.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21566.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20884.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44680.76,
Inpatient,522,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26239.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27166.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27166.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15337.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15508.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15508.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32153.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17108.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15508.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15027.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32153.3,
Inpatient,533,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16973.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20982.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20982.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12078.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12206.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12206.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25324.29,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13214.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12206.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11834.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25324.29,
Inpatient,534,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9470.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10417.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10417.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6511.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6564.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6564.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13657.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6561,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6564.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6380.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13657.58,
Inpatient,535,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14775.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16677.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16677.79,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9810.1,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9907.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9907.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20570.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10503.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9907.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20570.4,
Inpatient,536,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9248.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10123.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10123.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6356.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6407.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6407.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13332.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6375.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6407.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6227.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13332.32,
Inpatient,537,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11210.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12437.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12437.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7575.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7642.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7642.94,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15887.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7832.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7642.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7422.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15887.51,
Inpatient,538,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8667.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9120.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9120.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5827.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5871.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5871.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12224.43,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5743.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5871.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5710.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12224.43,
Inpatient,539,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23343.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25522.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25522.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14471.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14630.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14630.75,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30338.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16073.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14630.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14178.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,30338.1,
Inpatient,540,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15599.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16697.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16697.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9820.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9917.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9917.73,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20591.7,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10515.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9917.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9621.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20591.7,
Inpatient,541,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10105.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11034.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11034.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6836,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6893.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6893.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14337.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6948.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6893.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6698.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14337.93,
Inpatient,542,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21683.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23455.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23455.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13381.99,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13527.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13527.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28055.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14771.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13527.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13111.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28055.6,
Inpatient,543,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12526.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14028.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14028.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8413.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8492.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17644.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8834.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8492.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8244.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17644.49,
Inpatient,544,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9320.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9871.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9871.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6223.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6272.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638,100,,,per diem,pays based on per day rate,6272.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13053.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6216.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6272.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6097.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13053.89,
Inpatient,545,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29999.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32066.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32066.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17919.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18125.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1638,100,,,per diem,pays based on per day rate,18125.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37564.83,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20194.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18125.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17557.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,37564.83,
Inpatient,546,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14477.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15425.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15425.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9149.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9238.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9238.43,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19186.94,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9714.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9238.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8965.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19186.94,
Inpatient,547,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9990.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10461.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10461.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6601.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6655.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6655.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13846.45,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6588.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6655.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6468.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13846.45,
Inpatient,548,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24578.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25077.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25077.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14236.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14393.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14393.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29846.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15793.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14393.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13948.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,29846.66,
Inpatient,549,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14980.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15513.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15513.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9196.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9285.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9285.83,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19284.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9770.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9285.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9010.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19284.97,
Inpatient,550,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10533.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11843.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11843.07,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7416.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7481.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7481.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15553.73,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7458.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7481.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7266.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15553.73,
Inpatient,551,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19504.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21889.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21889.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12556.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12690.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12690.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26325.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13785.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12690.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12302.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26325.63,
Inpatient,552,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11306.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12428.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12428.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7570.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7638.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7638.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15877.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7827.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7638.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7417.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15877.58,
Inpatient,553,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15238.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17382.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17382.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10181.52,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10283.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10283.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21348.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10947.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10283.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9975.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,21348.74,
Inpatient,554,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9498.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10569.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10569.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6591.31,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6645.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6645.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13825.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6656.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6645.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6458.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13825.17,
Inpatient,555,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16401.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17993.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17993.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10503.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10610.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10610.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22023.42,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11331.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10610.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10291.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22023.42,
Inpatient,556,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9692.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10603.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10603.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6608.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6663.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6663.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13862.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6677.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6663.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6475.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13862.11,
Inpatient,557,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16768.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20023.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20023.13,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11573.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11693.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11693.87,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24264.73,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12610.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11693.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11339.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24264.73,
Inpatient,558,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10323.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11297.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11297.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6974.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7034.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7034.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14629.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7115.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7034.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6834.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14629.06,
Inpatient,559,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22355.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23800.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23800.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13563.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13711.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13711.08,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28436.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14989.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13711.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13289.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28436.24,
Inpatient,560,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12895.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14560.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14560.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8694.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8776.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8776.89,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18232.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9170.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8776.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8518.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,18232.48,
Inpatient,561,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9496.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10034.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10034.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6309.37,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6359.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6359.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13234.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6319.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6359.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6182.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13234.33,
Inpatient,562,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16920.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19558.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19558.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11328.33,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11445.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11445.93,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23751.98,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12317.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11445.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11099.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23751.98,
Inpatient,563,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10453.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11518.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11518.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7091.52,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7152.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7152.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14873.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7254.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7152.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6948.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14873.39,
Inpatient,564,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18260.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20088.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20088.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11607.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11728.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11728.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24337.13,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12651.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11728.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11372.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24337.13,
Inpatient,565,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12096.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12854,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12854,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7795.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7865.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7865.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16347.72,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8095.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7865.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7637.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16347.72,
Inpatient,566,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9011.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9652.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9652.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6108.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6155.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6155.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12812.47,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6079.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6155.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5984.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12812.47,
Inpatient,570,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34057.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37584.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37584.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20827.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21071.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21071.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43658.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23669.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21071.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20405.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,43658.11,
Inpatient,571,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19600.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21760.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21760.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12488.68,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12621.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12621.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26183.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13704.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12621.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12236.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26183.58,
Inpatient,572,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13236.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14657.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14657.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8745.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8828.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8828.41,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18339.02,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9230.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8828.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8568.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,18339.02,
Inpatient,573,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,66386.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,79975.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,79975.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,43166.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,43709.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,43709.08,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,90471.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,50366.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,43709.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42292.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,90471.24,
Inpatient,574,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38909.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43804.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,43804.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24105.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24393.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50526.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27586.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23617.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,50526.91,
Inpatient,575,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21131.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26315.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26315.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14888.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15053.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15053.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31213.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16572.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15053.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14587.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31213.05,
Inpatient,576,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60688.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,73094.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,73094.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,39540.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40034.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,40034.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82872.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,46033.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,40034.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38739.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,82872.38,
Inpatient,577,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30556.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34071.98,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34071.98,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18976.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19196.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19196.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39779.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21457.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19196.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18592.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,39779.12,
Inpatient,578,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19118.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20713.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20713.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11936.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12062.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12062.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25027.43,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13045.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12062.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11695.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25027.43,
Inpatient,579,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37691.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,42986.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,42986.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23674.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23956.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,23956.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49623.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27071.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23956.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23194.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,49623.53,
Inpatient,580,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20719.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22464.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22464.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12859.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12997.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12997.47,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26960.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14147.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12997.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12599.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26960.53,
Inpatient,581,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16500.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17320.88,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17320.88,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10148.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10250.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10250.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21280.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10908.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10250.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9943.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21280.53,
Inpatient,582,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19692.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21441.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21441.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12823.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12961.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12961.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26885.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13503.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12961.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12564.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26885.24,
Inpatient,583,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18474.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19574.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19574.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11336.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11454.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11454.16,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23769.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12327.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11454.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11107.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23769.01,
Inpatient,584,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22012.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25190.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25190.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14296.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14453.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14453.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29971.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15864.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14453.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14007.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,29971.66,
Inpatient,585,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20849.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21659.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21659.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12435.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12567.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12567.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26071.37,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13640.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12567.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12183.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26071.37,
Inpatient,592,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20306.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26882.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26882.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15187.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15356.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15356.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31839.37,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16929.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15356.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14880.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,31839.37,
Inpatient,593,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13670.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15561.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15561.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9221.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9311.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9311.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19337.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9800.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9311.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9035.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19337.5,
Inpatient,594,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9779.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10127.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10127.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6358.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6409.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6409.39,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13336.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6377.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6409.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6229.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13336.57,
Inpatient,595,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24167.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27974.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27974.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15763.04,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15939.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15939.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33045.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17617.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15939.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15444.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,33045.28,
Inpatient,596,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11921.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12977.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12977.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7860.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7931.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7931.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16484.08,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8172.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7931.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7701.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16484.08,
Inpatient,597,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19703.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20585.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20585.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11869.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11994.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11994.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24885.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12964.05,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11994.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11629.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24885.4,
Inpatient,598,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13338.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15418.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15418.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9146.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9235.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9235.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.86,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9710.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9235.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8961.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19179.86,
Inpatient,599,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8046.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7992.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7992.27,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5581.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5622.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5622.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11708.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5033.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5622.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5468.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11708.84,
Inpatient,600,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11947.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13189.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13189.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7971.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8044.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8044.73,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16718.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8306.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8044.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7811.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16718.4,
Inpatient,601,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8231.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8007.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8007.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5315.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5352.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5352.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11150.65,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5043.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5352.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5208,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11150.65,
Inpatient,602,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17378.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19131.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19131.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11103.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11217.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11217.89,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23280.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12048.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11217.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10878.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23280.41,
Inpatient,603,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10230.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11378.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11378.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7017.64,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7077.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7077.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14718.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7166.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7077.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6876.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14718.58,
Inpatient,604,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17712.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19372.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19372.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11230.04,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11346.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11346.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23546,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12200.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11346.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11003.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23546,
Inpatient,605,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10833.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11688.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11688.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7180.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7243.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7243.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15060.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7361.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7243.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7036.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15060.87,
Inpatient,606,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18122.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20396.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20396.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11769.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11893.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11893.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24676.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12844.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11893.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11531.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24676.64,
Inpatient,607,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9925.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11491.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11491.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7077.28,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7138.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14843.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7237.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7138.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6934.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14843.56,
Inpatient,614,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28640.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28969.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28969.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16287.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16471.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16471.45,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34144.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18244.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16471.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15958.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,34144.61,
Inpatient,615,MS-DRG,,,,,Inpatient,,,,,,16376,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18876.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18920.88,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18920.88,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10992.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11105.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11105.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23047.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11915.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11105.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10770.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,23047.46,
Inpatient,616,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47534.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,50902.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,50902.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27845.82,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28183.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,28183.97,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,58365.76,215,MS-DRG,,Case rate,215% Medicare MS-DRG,32057.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,28183.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27282.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,58365.76,
Inpatient,617,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24327.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25524.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25524.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14471.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14631.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14631.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30339.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16074.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14631.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14179.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30339.53,
Inpatient,618,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15618.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14938.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14938.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8893.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8978.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8978.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18650.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9408.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8978.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8714.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,18650.04,
Inpatient,619,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36694.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33292.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,33292.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18660.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18876.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18876.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39117.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20966.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18876.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18283.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,39117.24,
Inpatient,620,MS-DRG,,,,,Inpatient,,,,,,18058,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21125.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20864.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20864.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12016.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12143.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12143.05,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25193.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13139.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12143.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11773.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,25193.6,
Inpatient,621,MS-DRG,,,,,Inpatient,,,,,,16891,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19141.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19515.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19515.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11305.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11422.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11422.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23703.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12290.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11422.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11076.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,23703.64,
Inpatient,622,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43324.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,49203.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,49203.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26950.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27276.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27276.67,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,56489.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,30987.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27276.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26404.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,56489.49,
Inpatient,623,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22429.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23940.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23940.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13637.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13785.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13785.94,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28591.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15077.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13785.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13361.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28591.06,
Inpatient,624,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13170.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14334.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14334.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8575.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8656.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8656.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17982.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9027.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8656.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8402.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17982.51,
Inpatient,625,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34039.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37571.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37571.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20820.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21064.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21064.96,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43643.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23661.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21064.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20399.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,43643.87,
Inpatient,626,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19810.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19188.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19188.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11133.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11248.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11248.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23342.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12084.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11248.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10908.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23342.91,
Inpatient,627,MS-DRG,,,,,Inpatient,,,,,,13759,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14175.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15897.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15897.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9398.68,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9490.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9490.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19708.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10011.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9490.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9208.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,19708.24,
Inpatient,628,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44097.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,51633.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,51633.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28230.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28574.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,28574.09,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59172.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,32517.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,28574.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27659.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,59172.52,
Inpatient,629,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28108.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29103.5,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29103.5,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16358.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16542.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16542.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34292.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18328.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16542.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16027.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,34292.32,
Inpatient,630,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16890.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17958.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17958.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10485.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10591.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10591.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21985.07,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11310.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10591.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10273.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21985.07,
Inpatient,637,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16498.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18640.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18640.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10844.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10955.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10955.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22737.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11739.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10955.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10625.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22737.85,
Inpatient,638,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10539.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11567.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11567.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7117.27,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7178.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7178.64,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14927.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7285.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7178.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6973.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14927.36,
Inpatient,639,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7306.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8006.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8006.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5240.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5276.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5276.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10994.42,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5042.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5276.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5134.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10994.42,
Inpatient,640,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14751.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16915.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16915.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9935.48,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10034.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10034.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20833.15,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10653.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10034.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9734.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20833.15,
Inpatient,641,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9039.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10050.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10050.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6317.48,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6368.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6368.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13251.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6329.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6368.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6190.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13251.33,
Inpatient,642,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15458.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16762.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16762.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9854.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9952.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9952.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20664.15,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10556.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9952.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9655.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20664.15,
Inpatient,643,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19987.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21158.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21158.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12171.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12300.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12300.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25518.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13325.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12300.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11925.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25518.85,
Inpatient,644,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12222.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13655.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13655.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8217.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8293.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8293.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17232.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8599.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8293.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8051.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17232.6,
Inpatient,645,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9211.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9786.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9786.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6178.55,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6227.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6227.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12960.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6163.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6227.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6054,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12960.18,
Inpatient,650,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54180.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,57845.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,57845.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31504.48,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31891.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,31891.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,66032.79,215,MS-DRG,,Case rate,215% Medicare MS-DRG,36429.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,31891.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30866.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,66032.79,
Inpatient,651,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44325.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,44480.97,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,44480.97,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24461.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24754.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24754.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51274,215,MS-DRG,,Case rate,215% Medicare MS-DRG,28013.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24754.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23966.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,51274,
Inpatient,652,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38173.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38641.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38641.75,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21384.53,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21636.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21636.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44825.59,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24335.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21636.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20951.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44825.59,
Inpatient,653,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65428.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,69628.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,69628.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,37713.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38183.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,38183.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,79044.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,43850.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,38183.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36949.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,79044.58,
Inpatient,654,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34790.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35208.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,35208.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19575.55,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19803.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,19803.27,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41034.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22173.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19803.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19179.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,41034.71,
Inpatient,655,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24932.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27109.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27109.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15307.58,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15478.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15478.31,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32090.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17073.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15478.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14998.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32090.82,
Inpatient,656,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39370.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40354.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,40354.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22287.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22551.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,22551.27,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46717.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25414.56,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22551.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21836.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,46717.52,
Inpatient,657,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23187.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23719.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23719.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13520.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13667.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13667.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28346.75,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14938.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13667.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13247.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28346.75,
Inpatient,658,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18911.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19040.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19040.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11055.18,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11169.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11169.13,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23179.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11991.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11169.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10831.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23179.58,
Inpatient,659,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31956.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33297.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,33297.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18568.37,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18782.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18782.64,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38924.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20970.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18782.64,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18192.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,38924.1,
Inpatient,660,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17295.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17310.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17310.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10143.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10245.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10245.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21269.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10901.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10245.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9938.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21269.19,
Inpatient,661,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12748.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13484.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13484.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8127.15,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8202.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8202.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17043.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8492.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8202.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7963.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17043.64,
Inpatient,662,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35203.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38542.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38542.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21332.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21583.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,21583.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44716.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24273.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21583.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20900.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,44716.24,
Inpatient,663,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19170.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18765.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18765.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10910.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11022.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11022.15,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22875.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11817.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11022.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10689.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22875.62,
Inpatient,664,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14187.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13654,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13654,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8216.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8292.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8292.67,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17231.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8598.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8292.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8050.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17231.14,
Inpatient,665,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36454.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,39731.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,39731.14,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21958.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22218.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,22218.16,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46028.65,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25021.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22218.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21514.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,46028.65,
Inpatient,666,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20850.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22088.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22088.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12661.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12796.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12796.9,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26545.75,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13910.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12796.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12405.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26545.75,
Inpatient,667,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11955.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13499.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13499.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8135.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8210.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8210.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17060.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8501.76,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8210.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7971.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17060.71,
Inpatient,668,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33633.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36244.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36244.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20121.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20356.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,20356.17,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42178.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22825.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20356.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19714.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42178.1,
Inpatient,669,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18738.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19737.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19737.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11422.53,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11541.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11541.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23949.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12430.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11541.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11191.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,23949.38,
Inpatient,670,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11727.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12380.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12380.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7545.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7612.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,7612.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15825.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7797.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7612.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7393.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,15825.01,
Inpatient,671,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21348.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22017.98,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22017.98,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12624.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12759.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12759.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26467.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13866.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12759.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12369.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26467.64,
Inpatient,672,MS-DRG,,,,,Inpatient,,,,,,10272,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13787.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11867.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11867.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7375.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7440.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,7440.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15468.51,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7473.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7440.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7226.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,15468.51,
Inpatient,673,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41567.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47562.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,47562.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26085.61,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26400.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26400.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54677.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29953.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26400.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25557.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,54677.09,
Inpatient,674,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28562.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30639.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30639.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17167.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,17362.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35988.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19295.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17362.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16820.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,35988.22,
Inpatient,675,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21030.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20405.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20405.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11774.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11897.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11897.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24686.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12850.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11897.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11536.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24686.52,
Inpatient,682,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17650.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19302.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19302.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11193.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11309.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11309.24,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23469.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12156.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11309.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10967.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23469.32,
Inpatient,683,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10538.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11585.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11585.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7126.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7188.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7188.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14947.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7296.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7188.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14947.23,
Inpatient,684,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7285.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7826.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7826.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5145.61,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5180.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5180.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10795.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4928.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5180.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5042,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10795.58,
Inpatient,686,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22475.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23657.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23657.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13488.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13634.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13634.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28278.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14899.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13634.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13215.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28278.63,
Inpatient,687,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12585.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13444.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13444.36,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8106.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8180.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8180.72,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16999.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8466.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8180.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7942.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16999.62,
Inpatient,688,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8219.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10043.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10043.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6314.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6364.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6364.74,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13244.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6325.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6364.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6186.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13244.23,
Inpatient,689,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13353.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15104.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15104.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8981.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9067.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9067.43,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18833.31,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9512.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9067.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8799.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,18833.31,
Inpatient,690,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9516.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10378.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10378.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6490.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6543.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6543.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13613.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6535.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6543.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6359.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13613.52,
Inpatient,693,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16005.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18216.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18216.05,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10620.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10728.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10728.87,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22269.12,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11472.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10728.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10406.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22269.12,
Inpatient,694,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9242.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10066.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10066.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6326.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6377.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6377.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13269.79,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6339.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6377.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6198.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13269.79,
Inpatient,695,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13635.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15382.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15382.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9127.55,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9215.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9215.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19140.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9687.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9215.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8943.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19140.05,
Inpatient,696,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8292.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8901.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8901.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5712.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5754.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5754.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11982.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5606.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5754.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5597.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11982.97,
Inpatient,697,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11976.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14316.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14316.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8565.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8646.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8646.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17962.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9016.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8646.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8392.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17962.64,
Inpatient,698,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19303.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21278.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21278.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12234.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12364.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12364.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25650.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13400.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12364.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11987.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25650.97,
Inpatient,699,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12308.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13129.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13129.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7940.1,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8012.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8012.46,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16651.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8268.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8012.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7779.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16651.66,
Inpatient,700,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8946.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9109.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9109.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5822.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5866.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5866.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12213.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5737.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5866.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5704.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12213.05,
Inpatient,707,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23037.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25233.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25233.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14318.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14476.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14476.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30018.5,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15891.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14476.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30018.5,
Inpatient,708,MS-DRG,,,,,Inpatient,,,,,,16236,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17872.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18758.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18758.82,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10906.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11018.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11018.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22868.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11813.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11018.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10686.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,22868.52,
Inpatient,709,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27756.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27266.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27266.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15734.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15911,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15911,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32985.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17172,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15911,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15416.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32985.63,
Inpatient,710,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19195.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15875.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15875.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9814.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9911.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9911.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20578.92,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9997.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9911.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9615.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20578.92,
Inpatient,711,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25547.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27304.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27304.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15409.91,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15582.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15582.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32305.27,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17195.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15582.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15098.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32305.27,
Inpatient,712,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12704.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15284.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15284.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9076.05,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9163.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9163.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19032.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9626.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9163.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8892.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19032.14,
Inpatient,713,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17898.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18658.5,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18658.5,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10853.86,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10965.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10965.13,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22757.7,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11750.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10965.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10634.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22757.7,
Inpatient,714,MS-DRG,,,,,Inpatient,,,,,,10670,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11131.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12327.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12327.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7517.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7584.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,7584.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15766.79,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7763.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7584.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7366.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,15766.79,
Inpatient,715,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24228.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28392.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28392.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15983.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16163.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16163.08,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33506.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17880.75,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16163.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15660.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33506.91,
Inpatient,716,MS-DRG,,,,,Inpatient,,,,,,15832,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15290.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18291.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18291.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10660.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10769.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10769.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.9,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11519.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10769.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10445.31,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,22352.9,
Inpatient,717,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21580.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23327.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23327.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13314.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13458.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13458.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27913.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14690.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13458.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13045.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,27913.6,
Inpatient,718,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14796.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15122.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15122.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8990.65,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9077.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9077.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18853.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9523.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9077.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8809.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,18853.18,
Inpatient,722,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20525.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24113.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24113.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13728.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13877.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13877.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28781.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15185.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13877.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13450.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28781.41,
Inpatient,723,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13086.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14331.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14331.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8573.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8654.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8654.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17979.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9025.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8654.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8400.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17979.66,
Inpatient,724,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7767.48,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10411.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10411.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6507.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6561.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6561.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13650.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6556.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6561.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6376.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13650.46,
Inpatient,725,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15406.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15960.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15960.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9431.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9524.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9524.17,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19777.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10051.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9524.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9241.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19777.84,
Inpatient,726,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8925.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9400.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9400.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5975.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6021.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6021.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12534.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5920.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6021.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5854.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12534.09,
Inpatient,727,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17030.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20848.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20848.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12008.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12134.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12134.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25176.57,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13130.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12134.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11765.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25176.57,
Inpatient,728,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9656.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10290.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10290.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6444.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6496.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6496.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6480.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6496.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6314.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13516.95,
Inpatient,729,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12074.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12911.88,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12911.88,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7825.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7896.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7896.39,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16411.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8131.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7896.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7667.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16411.63,
Inpatient,730,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6818.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7994.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7994.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5234.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5270.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5270.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10981.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5034.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5270.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5128.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10981.63,
Inpatient,734,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26658.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27956.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27956.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15753.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15930.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15930.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33025.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17606.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15930.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15434.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33025.39,
Inpatient,735,MS-DRG,,,,,Inpatient,,,,,,14029,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16942,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16208.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16208.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9562.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9656.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9656.74,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20051.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10207.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9656.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9369.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,20051.99,
Inpatient,736,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51064.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,49996.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,49996.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27367.99,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27699.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27699.75,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57364.42,215,MS-DRG,,Case rate,215% Medicare MS-DRG,31486.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27699.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26813.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,57364.42,
Inpatient,737,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24666.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25386.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25386.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14399.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14557.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,14557.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30187.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15987.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14557.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14108.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30187.56,
Inpatient,738,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17688.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17551.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17551.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10270.31,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10373.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10373.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21534.8,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11053.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10373.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10062.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21534.8,
Inpatient,739,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45830.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46511.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,46511.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,25531.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25839.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,25839.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53516.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,29292.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,25839.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25015.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,53516.69,
Inpatient,740,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21592.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22983.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22983.89,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13133.25,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13274.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13274.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27534.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14474.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13274.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12867.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,27534.34,
Inpatient,741,MS-DRG,,,,,Inpatient,,,,,,14464,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15339.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16711.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16711.23,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9827.72,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9925.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9925.28,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20607.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10524.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9925.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9629.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,20607.32,
Inpatient,742,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20591.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22918.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22918.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13098.68,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13239.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13239.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27461.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14433.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13239.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12833.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,27461.89,
Inpatient,743,MS-DRG,,,,,Inpatient,,,,,,12935,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13576.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14945.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14945.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8897.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8982.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8982.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18657.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9412.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8982.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8717.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,18657.19,
Inpatient,744,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21517.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24210.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24210.9,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13779.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13930.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13930.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28889.33,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15247.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13930.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13501.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28889.33,
Inpatient,745,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14022.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13323.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13323.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8042.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8116.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8116.16,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16866.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8390.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8116.16,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7880.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,16866.11,
Inpatient,746,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19313.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21557.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21557.53,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12381.6,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12513.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12513.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25959.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13576.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12513.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12131.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25959.19,
Inpatient,747,MS-DRG,,,,,Inpatient,,,,,,9876,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11255.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11410.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11410.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7034.59,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7094.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,7094.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14754.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7186.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7094.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6892.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,14754.09,
Inpatient,748,MS-DRG,,,,,Inpatient,,,,,,15639,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16150.99,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18069.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18069.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10543.45,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10650.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10650.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22107.2,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11379.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10650.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10330.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1211.29,22107.2,
Inpatient,749,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32524.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32375.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32375.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18082.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18290.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18290.19,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37905.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20389.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18290.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17716.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,37905.71,
Inpatient,750,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17543.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17491.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17491.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10239.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10342.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10342.18,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21469.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11016,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10342.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10032.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21469.46,
Inpatient,754,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21887.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23826.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23826.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13577.2,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13724.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13724.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28464.67,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15005.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13724.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28464.67,
Inpatient,755,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13534.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13951.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13951.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8373.2,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8451.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8451.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17559.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8786.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8451.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8204.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17559.25,
Inpatient,756,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11007.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12729.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12729.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7729.31,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7798.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7798.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16209.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8016.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7798.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7573.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16209.93,
Inpatient,757,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18273.53,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19184.54,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19184.54,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11131.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11246.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11246.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23338.65,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12081.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11246.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10906.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23338.65,
Inpatient,758,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11621.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12766.54,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12766.54,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7748.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7818.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7818.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16251.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8040.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7818.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7592.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16251.1,
Inpatient,759,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8190.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8311.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8311.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5401.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5439.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5439.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11331.04,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5234.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5439.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5292.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11331.04,
Inpatient,760,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11027.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12802.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12802.56,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7767.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7837.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7837.99,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16290.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8062.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7837.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7611.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16290.87,
Inpatient,761,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7080.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7789.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7789.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5125.95,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5160.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5160.74,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10754.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4905.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5160.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5022.74,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10754.39,
Inpatient,768,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15666.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15666.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9277.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9367.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9367.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14366.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9367.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9090,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,15666.86,
Inpatient,769,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19386.94,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19857.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19857.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11485.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11605.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11605.25,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24081.46,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12505.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11605.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11253.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24081.46,
Inpatient,770,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10664.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10272.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10272.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6434.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6487,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,6487,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13497.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6469.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6487,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6305,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,13497.06,
Inpatient,776,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9282.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9217.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9217.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5878.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5923.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5923.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12332.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5805.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5923.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5760.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12332.36,
Inpatient,779,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12692.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12722.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12722.81,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7725.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7795.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7795.43,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16202.85,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8012.52,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7795.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7570.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16202.85,
Inpatient,783,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,3600,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22788.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22788.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13030.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3807,100,,,per diem,pays based on per day rate,4914,100,,,per diem,pays based on per day rate,13170.54,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19701.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13170.54,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12766.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22788.4,
Inpatient,784,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,3600,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13171.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13171.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7962.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8035.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3807,100,,,per diem,pays based on per day rate,4914,100,,,per diem,pays based on per day rate,8035.13,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13645.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8035.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7801.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,13645.21,
Inpatient,785,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,3600,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11142.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11142.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6892.93,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6951.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3807,100,,,per diem,pays based on per day rate,4914,100,,,per diem,pays based on per day rate,6951.3,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12367.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6951.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6753.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,12367.03,
Inpatient,786,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,3600,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22501.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22501.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12879.07,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13017.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3807,100,,,per diem,pays based on per day rate,4914,100,,,per diem,pays based on per day rate,13017.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19520.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13017.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12618.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22501.58,
Inpatient,787,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,3600,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13518.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13518.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8145.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8220.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3807,100,,,per diem,pays based on per day rate,4914,100,,,per diem,pays based on per day rate,8220.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13863.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8220.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7981.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,13863.91,
Inpatient,788,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,3600,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10996.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10996.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6816.35,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6873.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3807,100,,,per diem,pays based on per day rate,4914,100,,,per diem,pays based on per day rate,6873.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12275.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6873.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6678.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,12275.5,
Inpatient,789,MS-DRG,,,,,Inpatient,,,,,,20254,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20614.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23400.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23400.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13352.85,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13497.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13497.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4868,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27994.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14737.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13497.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13082.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27994.53,
Inpatient,790,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67980.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,77171.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,77171.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,41688.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42211.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,42211.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,9462,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,87374.9,215,MS-DRG,,Case rate,215% Medicare MS-DRG,48600.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,42211.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40844.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,87374.9,
Inpatient,791,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46427.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,52703.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,52703.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28794.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29145.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,29145.53,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,5297,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60354.24,215,MS-DRG,,Case rate,215% Medicare MS-DRG,33191.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,29145.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28211.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,60354.24,
Inpatient,792,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28013.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31800.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31800.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17779.43,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17983.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,17983.17,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4868,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37270.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20027.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17983.17,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17419.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,37270.81,
Inpatient,793,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47690.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,54138.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,54138.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,29551.12,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29912.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,29912.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,5297,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,61939.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,34095.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,29912.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28952.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,61939.36,
Inpatient,794,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16879.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19162.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19162.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11119.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11234.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11234.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4868,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23314.48,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12068.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11234.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10894.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23314.48,
Inpatient,795,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,2594.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,2594.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,2388.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,2386.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,2386.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4778,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5017.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,1633.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2386.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2340.67,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,5017.62,
Inpatient,796,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18243.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18243.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10634.96,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10743.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,3822,100,,,per diem,pays based on per day rate,10743.3,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15989.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10743.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10420.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,18243.06,
Inpatient,797,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12808.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12808.99,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7771.33,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7841.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,3822,100,,,per diem,pays based on per day rate,7841.43,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12566.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7841.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7614.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,12808.99,
Inpatient,798,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10433.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10433.43,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6681.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6737.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,3822,100,,,per diem,pays based on per day rate,6737.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11070.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6737.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6546.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,11070.72,
Inpatient,799,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,61691.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,63724.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,63724.68,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,34602.61,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35030.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,35030.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72525.18,215,MS-DRG,,Case rate,215% Medicare MS-DRG,40132.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,35030.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33901.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,72525.18,
Inpatient,800,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35402.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,36240.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,36240.47,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20119.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20354.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,20354.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42173.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22823.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20354.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19712.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42173.84,
Inpatient,801,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20182.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23018.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23018.62,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13151.56,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13293.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13293.5,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27572.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14496.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13293.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12885.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,27572.71,
Inpatient,802,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44484.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43605.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,43605.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,24274.59,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24565.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24565.05,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50881.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27461.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24565.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23783.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,50881.96,
Inpatient,803,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22609.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23899.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23899.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13615.83,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13763.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13763.97,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28545.63,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15051.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13763.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13340.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28545.63,
Inpatient,804,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16370.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15567.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15567.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9225.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9314.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9314.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19344.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9804.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9314.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9038.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19344.64,
Inpatient,805,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12967.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12967.19,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7854.7,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7925.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,3822,100,,,per diem,pays based on per day rate,7925.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12666.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7925.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7696.18,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12967.19,
Inpatient,806,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9603.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9603.85,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6082.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6129.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,3822,100,,,per diem,pays based on per day rate,6129.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10548.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6129.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5959.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10548.27,
Inpatient,807,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,3775,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,2000,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8415.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8415.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5456.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5495.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,2301,100,,,per diem,pays based on per day rate,3822,100,,,per diem,pays based on per day rate,5495.22,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9799.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5495.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5346.13,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,9799.83,
Inpatient,808,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26196.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28168.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28168.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15865.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16043.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,16043.56,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33259.75,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17739.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16043.56,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15544.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,33259.75,
Inpatient,809,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14662.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15490.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15490.66,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9184.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9273.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9273.47,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19259.41,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9755.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9273.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8999.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19259.41,
Inpatient,810,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11525.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12919.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12919.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7829.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7900.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7900.51,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16420.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8136.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7900.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7671.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16420.17,
Inpatient,811,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16530.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18052.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18052.71,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10534.63,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10641.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10641.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22088.72,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11369.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10641.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10321.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22088.72,
Inpatient,812,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10550.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11584.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11584.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7126.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7187.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7187.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14945.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7295.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7187.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6982.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14945.82,
Inpatient,813,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18518.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20064.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20064.28,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11594.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11715.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11715.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24310.16,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12636,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11715.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11360.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24310.16,
Inpatient,814,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22672.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27371.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27371.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15445.15,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15617.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15617.72,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32379.13,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17237.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15617.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15132.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,32379.13,
Inpatient,815,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11905.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12787.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12787.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7759.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7829.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7829.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16273.84,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8053.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7829.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7603.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16273.84,
Inpatient,816,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7923.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9134.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9134.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5834.9,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5879.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5879.15,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12240.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5752.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5879.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5717.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12240.05,
Inpatient,817,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27647,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29003.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29003.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20113.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20347.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,20347.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,42161.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18265.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20347.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19706.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,42161.05,
Inpatient,818,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16297.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15088.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15088.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10721.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10830.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10830.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22479.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9502.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10830.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,22479.34,
Inpatient,819,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11831.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11668.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11668.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7170.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7232.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,7232.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15038.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7348.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7232.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7025.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,15038.14,
Inpatient,820,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68215.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,77770.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,77770.96,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42004.65,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42531.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,42531.85,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88036.77,215,MS-DRG,,Case rate,215% Medicare MS-DRG,48978.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,42531.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41154.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,88036.77,
Inpatient,821,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25830.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28708.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28708.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16150.04,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16332.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16332.02,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33856.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18080.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16332.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15823.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33856.28,
Inpatient,822,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14999.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15933.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15933.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9417.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9509.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9509.75,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19748.03,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10034.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9509.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9227.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19748.03,
Inpatient,823,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,53954.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,57902.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,57902.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31534.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31921.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,31921.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,66095.27,215,MS-DRG,,Case rate,215% Medicare MS-DRG,36465.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,31921.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30895.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,66095.27,
Inpatient,824,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28337.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28718.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28718.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16155.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16337.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16337.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33867.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18086.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16337.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15828.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,33867.66,
Inpatient,825,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16796.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16609.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16609.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9774.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9871.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9871.02,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20495.11,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10460.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9871.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9576.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20495.11,
Inpatient,826,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,60458.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,56447.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,56447.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,32386.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32785.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,32785.73,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,67882.07,215,MS-DRG,,Case rate,215% Medicare MS-DRG,35549.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,32785.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31731.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,67882.07,
Inpatient,827,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29969.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29803.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,29803.18,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16726.84,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16916.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,16916.52,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35065.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18769.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16916.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16388.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,35065.01,
Inpatient,828,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20062.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21098.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21098.37,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12139.61,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12268.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12268.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25452.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13287.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12268.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11894.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25452.09,
Inpatient,829,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38452.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40563.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,40563.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22397.15,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22662.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,22662.55,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46947.62,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25545.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22662.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21943.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,46947.62,
Inpatient,830,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17761.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20336.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20336.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11738.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11861.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11861.45,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24611.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12807.72,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11861.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11501.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24611.28,
Inpatient,831,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13444.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12987.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12987.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8309.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8386.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8386.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17425.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8179.38,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8386.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8141.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17425.74,
Inpatient,832,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9327.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9488.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9488.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6021.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6068.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6068.04,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12630.66,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5975.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6068.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5899.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12630.66,
Inpatient,833,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6435.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6582.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,6582.63,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4490.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4516.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,4516.48,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9422.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4145.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4516.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4399.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,9422.09,
Inpatient,834,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,72535.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,72012.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,72012.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,38970.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,39456.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,39456.92,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,81677.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,45351.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,39456.92,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38181.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,81677.89,
Inpatient,835,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25332.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,28752.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,28752.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,16173.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,16355.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,16355.38,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33904.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,18107.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,16355.38,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15845.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,33904.58,
Inpatient,836,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14064.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15399.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15399.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10590.88,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10698.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10698.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22206.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9698.13,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10698.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10376.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22206.6,
Inpatient,837,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,68306.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,61178.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,61178.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,33852.98,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34271.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,34271.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,70954.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,38528.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,34271.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,33167.55,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,70954.26,
Inpatient,838,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27088.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25111.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25111.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14588.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14749.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,14749.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30583.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15814.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14749.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14293.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,30583.82,
Inpatient,839,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17824.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16760.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16760.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9853.47,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9951.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9951.37,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20661.29,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10555.11,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9951.37,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9654.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20661.29,
Inpatient,840,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38597.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,40195.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,40195.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22203.3,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22466.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,22466.11,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46541.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,25314.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,22466.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21753.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,46541.4,
Inpatient,841,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19434.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20237.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20237.92,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11686.19,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11808.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11808.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24501.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12745.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11808.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11450.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24501.91,
Inpatient,842,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13147.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13715.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13715.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8249.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8325.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8325.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17299.35,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8637.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8325.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8082.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17299.35,
Inpatient,843,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22862.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23930.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23930.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13632.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13780.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13780.44,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28579.68,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15070.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13780.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13356.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28579.68,
Inpatient,844,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14192.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14883.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,14883.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8864.59,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8949.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8949.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18589,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9373.32,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8949.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8685.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,18589,
Inpatient,845,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10174.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11124.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11124.1,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6883.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6941.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6941.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14437.35,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7005.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6941.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6744.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14437.35,
Inpatient,846,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32034.71,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31434.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31434.04,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17586.26,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17787.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,17787.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36865.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19796.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,17787.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17230.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,36865.99,
Inpatient,847,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16013.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15596.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15596.12,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9240.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9329.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9329.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19375.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,9822.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9329.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9053.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19375.89,
Inpatient,848,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12372.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9768.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,9768.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6688.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6744.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6744.57,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14029.72,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6151.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6744.57,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6554.03,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14029.72,
Inpatient,849,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29885.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34616.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,34616.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19263.08,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19486.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,19486.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40379.92,215,MS-DRG,,Case rate,215% Medicare MS-DRG,21800.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19486.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18873.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,40379.92,
Inpatient,853,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59539.08,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,64299.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,64299.6,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,34905.57,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,35337.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,35337.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,73160.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,40494.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,35337.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,34198.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,73160.06,
Inpatient,854,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25434.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26214.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26214.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14835.83,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15000.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15000.26,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31102.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16509.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15000.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14535.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,31102.23,
Inpatient,855,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18214.8,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21888.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21888.08,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12555.79,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12689.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12689.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26324.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13784.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12689.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12301.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26324.22,
Inpatient,856,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55896.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,56956.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,56956.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,31036.14,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,31416.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,31416.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,65051.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,35870.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,31416.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30407.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,65051.34,
Inpatient,857,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25197.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27468.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27468.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15496.66,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15669.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15669.91,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32487.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17299.17,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15669.91,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15183.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32487.06,
Inpatient,858,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16294.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16506.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16506.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9719.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9816.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9816.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20381.47,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10395.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9816.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9523.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,20381.47,
Inpatient,862,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22731.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23691.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23691.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13506.02,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13652.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13652.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28315.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14920.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13652.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13232.97,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28315.52,
Inpatient,863,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12121.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12932.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12932.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7836.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7907.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7907.35,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16434.3,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8144.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7907.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7678.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16434.3,
Inpatient,864,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10504.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11354.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11354.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7004.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7064.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7064.63,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14691.59,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7150.68,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7064.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6863.47,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14691.59,
Inpatient,865,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17711.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21091.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21091.93,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12136.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12264.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12264.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25445.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13283.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12264.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11890.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25445.01,
Inpatient,866,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10055.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11803.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11803.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7241.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7304.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7304.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15187.31,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7433.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7304.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7095.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15187.31,
Inpatient,867,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26811.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26910.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26910.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15202.51,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15371.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15371.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31870.64,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16947.63,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15371.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14895.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,31870.64,
Inpatient,868,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12776.01,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13961.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13961.4,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8378.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8456.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8456.83,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17570.61,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8792.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8456.83,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8209.48,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17570.61,
Inpatient,869,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8731.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8883.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8883.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5702.74,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5745.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5745.23,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11963.1,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5594.67,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5745.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5587.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11963.1,
Inpatient,870,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,77171.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,89580.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,89580.59,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,48228.03,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,48838.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,48838.33,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,101078.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,56415.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,48838.33,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47251.26,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,101078.38,
Inpatient,7,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,138786.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,157767,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,157767,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,84160.53,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,85250.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,85250.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176377.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,99357.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,85250.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,82455.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,176377.95,
Inpatient,872,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12300.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13246.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13246.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8001.77,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8074.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8074.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16780.9,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8342.19,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8074.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7840.27,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16780.9,
Inpatient,876,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39166.98,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47993.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,47993.51,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26312.69,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26630.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26630.36,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55152.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,30225.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26630.36,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25780.08,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,55152.96,
Inpatient,880,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10361.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12277.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12277.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7491.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7557.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7557.77,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15711.39,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7732.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7557.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7340.25,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15711.39,
Inpatient,881,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9611.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11659.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11659.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7165.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7227.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7227.4,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15028.19,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7342.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7227.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7020.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15028.19,
Inpatient,882,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9870.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12081.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12081.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7387.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7452.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7452.7,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15494.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7608.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7452.7,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7238.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15494.09,
Inpatient,883,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,18957.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24120.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24120.87,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13732.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13882.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13882.1,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28789.92,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15190.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13882.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13454.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28789.92,
Inpatient,884,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17345.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22596.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22596.76,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12929.24,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13068.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13068.22,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27106.83,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14230.89,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13068.22,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12667.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27106.83,
Inpatient,885,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14854.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17574.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17574.25,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10282.5,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10386.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10386.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21560.36,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11067.84,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10386.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10074.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,21560.36,
Inpatient,886,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14666.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21629.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21629.55,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12419.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12551.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12551.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26038.71,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13621.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12551.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12168.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26038.71,
Inpatient,887,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12941.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16663.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16663.64,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9802.65,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9899.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9899.87,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20554.79,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10494.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9899.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9604.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,20554.79,
Inpatient,894,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6579.77,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7389.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7389.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,4915.17,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4947.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,4947.14,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10312.68,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4653.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,4947.14,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4816.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10312.68,
Inpatient,895,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19166.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20691.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20691.94,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11925.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12051.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12051.01,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25003.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13031.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12051.01,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11684.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,25003.28,
Inpatient,896,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21336.9,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22869.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22869.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13072.91,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13213.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13213.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27407.89,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14402.61,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13213.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12808.63,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27407.89,
Inpatient,897,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9911.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11004.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11004.49,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6820.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6877.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6877.81,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14305.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6930.36,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6877.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6682.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14305.25,
Inpatient,901,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,51160.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,55662.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,55662.95,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,30354.29,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,30725.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,30725.93,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,63622.47,215,MS-DRG,,Case rate,215% Medicare MS-DRG,35055.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,30725.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,29739.77,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,63622.47,
Inpatient,902,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23542.14,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24240.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24240.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13795.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13945.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13945.96,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28921.97,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15266.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13945.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13516.5,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28921.97,
Inpatient,903,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13606.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15967.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,15967.83,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9435.97,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9528.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,9528.3,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19786.37,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10056.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9528.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9245.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,19786.37,
Inpatient,904,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,44668.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41880.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41880.33,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23091.2,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23365.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,23365.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,48402.05,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26375.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23365.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22623.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,48402.05,
Inpatient,905,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19775.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20369.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20369.11,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11755.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11878.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,11878.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24646.78,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12827.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11878.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11517.75,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,24646.78,
Inpatient,906,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21618.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,24200.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,24200.61,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13774.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13924.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13924.68,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28877.98,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15240.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13924.68,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13495.93,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28877.98,
Inpatient,907,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47319.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,47839.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,47839.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,26231.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26547.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,26547.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,54982.53,215,MS-DRG,,Case rate,215% Medicare MS-DRG,30127.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,26547.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25700.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,54982.53,
Inpatient,908,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24574.04,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,25776.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,25776.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14604.71,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14766.06,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30617.91,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16233.21,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,14766.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14309.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,30617.91,
Inpatient,909,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16431.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17444.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17444.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10214.06,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10316.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,10316.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21416.93,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10986.03,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10316.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10007.72,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,21416.93,
Inpatient,913,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19638.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19221.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19221.84,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11150.76,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11265.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11265.99,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23379.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12105.45,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11265.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10925.44,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23379.87,
Inpatient,914,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10629.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11674.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11674.58,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7173.53,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7235.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7235.65,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15045.26,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7352.37,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7235.65,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7028.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15045.26,
Inpatient,915,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.51,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22816.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22816.69,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13045.13,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13185.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13185.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27349.69,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14369.4,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13185.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12781.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,27349.69,
Inpatient,916,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7890.92,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8473.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8473.3,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5486.52,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5526.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5526.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11509.99,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5336.28,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5526.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5376,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11509.99,
Inpatient,917,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17719.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20526.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,20526.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11838.01,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11962.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11962.41,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,24820.06,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12926.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11962.41,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11598.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,24820.06,
Inpatient,918,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9487.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11072.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,11072.65,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6856.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6914.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6914.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14380.52,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6973.29,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6914.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6718.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14380.52,
Inpatient,919,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22101.54,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23468.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23468.78,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13388.78,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,13533.89,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28069.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14780.07,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13533.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13118.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,28069.82,
Inpatient,920,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12279.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13296.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13296.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8028.23,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8101.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8101.76,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16836.34,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8373.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8101.76,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7866.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16836.34,
Inpatient,921,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8364.33,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8974.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8974.91,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5750.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5794,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5794,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12063.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5652.18,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5794,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5634.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,12063.95,
Inpatient,922,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19034.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22442.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,22442.42,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12847.91,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12985.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,12985.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26936.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,14133.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12985.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12588.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,26936.38,
Inpatient,923,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11263.5,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13008.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13008.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7876.39,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7947.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7947.89,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,16518.15,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8192.34,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7947.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7717.43,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,16518.15,
Inpatient,927,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,252779.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,339018.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,339018.22,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,179675.33,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,182040.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,182040.78,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,376537.17,215,MS-DRG,,Case rate,215% Medicare MS-DRG,213505.47,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,182040.78,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,176034.51,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,376537.17,
Inpatient,928,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,78281.23,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,88999.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,88999.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,47921.67,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,48527.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,48527.88,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,100436.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,56049.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,48527.88,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46951.11,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,100436.38,
Inpatient,929,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,36121.59,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41356.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41356.86,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22815.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23086.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,23086.32,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47823.96,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26045.55,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23086.32,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22353.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,47823.96,
Inpatient,933,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27120.86,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,38996.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,38996.74,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,21571.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21825.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,21825.99,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,45217.65,215,MS-DRG,,Case rate,215% Medicare MS-DRG,24559.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21825.99,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21135.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,45217.65,
Inpatient,934,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23261.69,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26913.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26913.15,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15203.86,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15373.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15373.21,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31873.49,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16949.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15373.21,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14896.4,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,31873.49,
Inpatient,935,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23165.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26252.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,26252.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,14855.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15020.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,15020.19,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,31143.45,215,MS-DRG,,Case rate,215% Medicare MS-DRG,16532.91,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15020.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14555.09,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,31143.45,
Inpatient,939,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40444.58,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41354.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,41354.29,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,22813.99,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23084.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,23084.95,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,47821.14,215,MS-DRG,,Case rate,215% Medicare MS-DRG,26043.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,23084.95,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22352.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,47821.14,
Inpatient,940,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26617.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27866.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,27866.2,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,15706.09,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15882.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,15882.15,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32925.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,17549.46,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,15882.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15388.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,32925.95,
Inpatient,941,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23048.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23871.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,23871.35,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,13600.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13748.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,13748.86,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,28514.38,215,MS-DRG,,Case rate,215% Medicare MS-DRG,15033.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,13748.86,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13325.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,28514.38,
Inpatient,945,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19414.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19414.77,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11252.4,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11368.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11368.98,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12226.95,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11368.98,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11025.02,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19414.77,
Inpatient,946,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13025.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13025.06,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7885.2,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7956.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7956.82,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8202.87,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7956.82,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7726.06,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13025.06,
Inpatient,947,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14310.09,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,16097.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,16097.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,9504.41,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9597.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,9597.66,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19929.81,215,MS-DRG,,Case rate,215% Medicare MS-DRG,10137.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,9597.66,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9312.46,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,19929.81,
Inpatient,948,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,9433.39,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10302.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10302.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6450.34,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6502.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6502.8,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13529.74,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6488.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6502.8,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6320.28,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,13529.74,
Inpatient,949,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13302.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13326.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13326.03,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8292.54,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8369.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,8369.61,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17390.23,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8392.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8369.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8125.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,17390.23,
Inpatient,950,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8871.3,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8079.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,8079.73,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5349.62,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5387.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5387.39,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11223.09,215,MS-DRG,,Case rate,215% Medicare MS-DRG,5088.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5387.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,5241.87,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,11223.09,
Inpatient,951,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6706.81,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7588.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,7588.41,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,5020.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,5053.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,5053.59,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10532.82,215,MS-DRG,,Case rate,215% Medicare MS-DRG,4779,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,5053.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,4919.15,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,10532.82,
Inpatient,955,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,75377.26,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,78330.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,78330.45,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,42299.46,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,42830.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,42830.6,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88654.58,215,MS-DRG,,Case rate,215% Medicare MS-DRG,49330.62,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,42830.6,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41442.85,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,88654.58,
Inpatient,956,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46142.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,49880.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,49880.32,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,27306.99,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27637.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,27637.94,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,57236.6,215,MS-DRG,,Case rate,215% Medicare MS-DRG,31413.42,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,27637.94,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26754.23,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,57236.6,
Inpatient,957,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,88939.49,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,93022.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,93022.39,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,50041.77,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,50676.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,50676.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,104879.22,215,MS-DRG,,Case rate,215% Medicare MS-DRG,58583.25,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,50676.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,49028.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,104879.22,
Inpatient,958,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50405.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,52023.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,52023.09,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,28436.16,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,28782.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,28782.2,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,59602.88,215,MS-DRG,,Case rate,215% Medicare MS-DRG,32762.88,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,28782.2,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,27860.52,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,59602.88,
Inpatient,959,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32792.16,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32571.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,32571.02,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,18185.42,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18394.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18394.58,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,38121.59,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20512.44,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18394.58,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17817.53,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,38121.59,
Inpatient,963,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32717.85,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,35167.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,35167.8,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19553.87,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19781.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,19781.3,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,40989.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,22147.83,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,19781.3,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19158.24,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,40989.28,
Inpatient,964,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17879.22,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19305.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,19305.44,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,11194.8,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11310.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,11310.62,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23472.16,215,MS-DRG,,Case rate,215% Medicare MS-DRG,12158.1,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,11310.62,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10968.59,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,23472.16,
Inpatient,965,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10936.31,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12294.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,12294.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,7500.22,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7566.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,7566.71,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15729.87,215,MS-DRG,,Case rate,215% Medicare MS-DRG,7742.79,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,7566.71,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,7348.89,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,15729.87,
Inpatient,969,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,70135.02,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,88393.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,88393.46,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,47602.44,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,48204.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,48204.39,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,99767.4,215,MS-DRG,,Case rate,215% Medicare MS-DRG,55668.06,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,48204.39,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,46638.35,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,99767.4,
Inpatient,970,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,35819.57,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,30924.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,30924.72,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,19860.89,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20092.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,20092.42,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,41632.67,215,MS-DRG,,Case rate,215% Medicare MS-DRG,19475.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,20092.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19459.04,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,41632.67,
Inpatient,974,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32245.64,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,37511.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,37511.21,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,20788.77,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,21032.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,21032.69,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,43577.13,215,MS-DRG,,Case rate,215% Medicare MS-DRG,23623.65,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,21032.69,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20368.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,43577.13,
Inpatient,975,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15365.97,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17534.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,17534.38,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10261.49,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10364.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10364.84,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,21516.32,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11042.73,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10364.84,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10054.19,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,21516.32,
Inpatient,976,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11380.96,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10872.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,10872.01,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,6750.59,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6807.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,6807.07,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,14158.95,215,MS-DRG,,Case rate,215% Medicare MS-DRG,6846.93,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,6807.07,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,6614.45,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,14158.95,
Inpatient,977,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,15871.74,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,18213.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,18213.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,10619.36,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10727.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1269,100,,,per diem,pays based on per day rate,1638,100,,,per diem,pays based on per day rate,10727.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,22266.28,215,MS-DRG,,Case rate,215% Medicare MS-DRG,11470.41,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,10727.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,946,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,10404.81,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,22266.28,
Inpatient,981,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,55304.78,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,60969.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,60969.7,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,33150.81,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,33559.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,33559.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,69482.8,215,MS-DRG,,Case rate,215% Medicare MS-DRG,38397.24,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,33559.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,32479.61,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,69482.8,
Inpatient,982,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,30401.15,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,31974.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,31974.24,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,17870.94,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,18075.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,18075.9,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,37462.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,20136.6,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,18075.9,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17509.42,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,37462.56,
Inpatient,983,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,19802.82,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21031.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21031.48,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12104.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12232.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12232.34,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,25378.25,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13245.12,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12232.34,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,11859.73,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,25378.25,
Inpatient,987,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,39261.66,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,43430.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,43430.17,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,23907.92,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,24193.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,24193.49,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,50113.56,215,MS-DRG,,Case rate,215% Medicare MS-DRG,27351.27,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,24193.49,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,23424.05,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,50113.56,
Inpatient,988,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,20451.2,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,21826.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,21826.34,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,12523.24,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12656.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,12656.79,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,26256.01,215,MS-DRG,,Case rate,215% Medicare MS-DRG,13745.7,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,12656.79,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,12270.1,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,26256.01,
Inpatient,989,MS-DRG,,,,,Inpatient,,,,,,1000,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,13466.35,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,1300,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,13894.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,,,,,Other,Not Separately reimbursable,13894.52,150,CUSTOM-DRG,,Case rate,150% Medicare CUSTOM-DRG,8343.38,103,MS-DRG,,Case rate,103% Medicare MS-DRG,1398.25,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8421.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1500,100,,,per diem,pays based on per day rate,2752,100,,,per diem,pays based on per day rate,8421.12,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,17496.78,215,MS-DRG,,Case rate,215% Medicare MS-DRG,8750.43,100,CUSTOM-DRG,,Case rate,100% Medicare CUSTOM-DRG,8421.12,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1645,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,8174.96,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1000,17496.78,
Inpatient,998,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable ,1211.29,100,,,per diem,pays based on per day rate,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2152.77,215,MS-DRG,,Case rate,215% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,4273,
Inpatient,999,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable ,1211.29,100,,,per diem,pays based on per day rate,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1050,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.32,103,MS-DRG,,Case rate,103% Medicare MS-DRG,804.1,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1001.29,100,TRICARE-DRG,,Case rate,100% TRICARE DRG,4273,100,,,per diem,pays based on per day rate,,,,,Other,Not Separately reimbursable,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,2152.77,215,MS-DRG,,Case rate,215% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1211.29,100,,,per diem,pays based on per day rate,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,1001.29,100,MS-DRG,,Case rate,100% Medicare MS-DRG,804.1,4273,